“When Michael Adams was researching health insurance options last year, he had one very specific requirement: coverage for prosthetic limbs,” Michelle Andrews writes over at KFF Health News. “Adams, 51, lost his right leg to cancer 40 years ago, and he has worn out more legs than he can count. He picked a gold plan on the Colorado health insurance marketplace that covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. That function adds stability and helps prevent falls. But when his leg needed replacing in January after about five years of everyday use, his new marketplace health plan wouldn’t authorize it. The roughly $50,000 leg with the electronically controlled knee wasn’t medically necessary, the insurer said, even though Colorado law leaves that determination up to the patient’s doctor, and his has prescribed a version of that leg for many years, starting when he had employer-sponsored coverage. ‘The electronic prosthetic knee is life-changing,’ said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, ‘it would be like going back to having a wooden leg like I did when I was a kid.’ The microprocessor in the knee responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling. … In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis…. To people in the amputee community, the coverage disparity amounts to discrimination. ‘Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,’ said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago. AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition.” Michelle Andrews, “Health insurers limit coverage of prosthetic limbs, questioning their medical necessity,” KFF News.
