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Living Better: How to Get Better Prosthetic Devices Through Your Insurer

Posted by Bryan Potok, CPO on

For many people, any effort to improve their quality of life is considered priceless. After all, increased independence or an enhanced everyday living experience outweighs any amount saved. The modern technology consumer culture is an excellent example of this principle in action. Whether it’s the latest smartphone or laptop, its cost is often justified by how it improves working and living.  

Getting approval for prosthetic devices takes paperwork and a solid letter of medical justification.

Things are no different for an amputee. The medical community is always coming up with the best solutions so thousands of people can enjoy their lives and reclaim independence. However, the journey to getting the latest and best assistive devices is not as simple as getting the latest smartphone. Depending on your insurance provider, upgrading to a better machine can take a while. The process can have you jumping through hoops and numerous rules which is why we, at Amputee Store, wrote this guide for you. Below are some tips and tricks that can help prepare you to advocate for yourself, especially when your insurer says you are not qualified to get the device on their dime. 

But isn’t the purpose of getting medical insurance is to be prepared for cases like this? After all, you pay high premiums per month.

Here’s the unvarnished truth: most insurance companies don’t want to pay for a steeply priced device when they are not convinced you need it. If you can’t produce proof that the new machine is a medical necessity, you can expect your insurer to assure you that you are better off with a cheaper, less technologically-advanced device. 

In this article, you’ll learn how to build a solid case for yourself as well as how to make an appeal when your insurer denies your claim.

Understand your insurance plan

The success of your claims depends on one thing: understanding how your health insurance works. 

It’s unfortunate that most Americans don’t take the time to understand their health insurance. According to a survey by the Kaiser Family Foundation, 4 out of 10 respondents said that they don’t understand basic health insurance terms. Even fewer said that they could calculate how much they owe under their insurance plan. 

While the statistics are alarming, this widespread apathy is understandable because health insurance can be complicated. But knowing how your insurance works can help you navigate the health care system with lesser chances of ending up with a costly and unexpected prosthetic bill. So, we suggest that you study your health insurance plan closely this time.

If you don’t have a copy of the Summary Plan Description, which is also sometimes referred to as Summary of Benefits, call your insurer as soon as possible and request for one. This document tells you which services are covered by your plan, what isn’t included, and the amount you need to pay.  

As you’re reviewing your plan, take note of your deductible and maximum out-of-pocket expenses (the amount allowed to cover for assistive devices), and if there are annual or lifetime caps. After all, you wouldn’t want to blow everything away on one machine which you may have to replace a few years down the line. 

If there are sections you don’t understand, go ahead and contact your health plan provider. But we suggest writing down all your questions, so you don’t end up making numerous follow up calls. 

However, if you are not insured, and you wish to make the upgrade, talk to your healthcare team. Other sources of funding may be available to you. All you need to do is ask. 

Maintain your own records

If you’re not in the habit of maintaining your own records, then we suggest starting this invaluable habit now. It’ll save you a lot of time and effort especially when you have to switch doctors or specialists down the road. Once it’s time to file a petition or appeal to your health insurance provider, you have all the necessary documents on hand. 

In particular, you will need the following: information about your prosthesis, medical treatment, income, living expenses, dependents, employment, and more. With all these requests for information, keeping everything organized is essential to prevent delays. 

Work with your healthcare team

Your health care team consists of your physician, prosthetist, and your physical therapist. They can help you procure payment not only for your first but also for your future prosthetic devices. Primarily, your health care team provides you with valuable information that is required by your health insurer. This information can include any or all of the following: an exam, notes from a visit, or a physical. These documents help build the case that justifies the “medical necessity” of the device you want before funds are released to your prosthetic facility.  

For prosthetics, for example, the documentation from your prosthetist must show your current level of function or activity and your expected or potential level once you have the device. The document can also describe how the device will help improve your performance at work or increase your independence. 

Understanding medical necessity

We mentioned the importance of medical necessity above. But if this is your first time to acquire prosthesis from your health insurance provider, you may have wondered about its importance. We’ll break it down for you. 

Remember when we said at the beginning of the article that health insurance companies don’t want to pay more than what is medically necessary? It’s because they don’t want to spend more than they have to. So, merely wanting a new assistive device for the sake of wanting to upgrade is not enough.

While the concept of medical necessity is understandable, the rules are sometimes questionable. That is why it’s crucial that you build a solid, medical necessity case for yourself. Medical necessity needs to be demonstrated because, more often than not, this need increases with the price tag. 

Persistence is key

If your health insurer denies your application, you need to be persistent. You still have 1 or 2 chances to appeal, depending on your insurer. 

As soon as you receive the information that your request is denied, ask them for a written copy of the reason for rejecting the claim. This is also another vital documentation. Review the letter and then call your insurance provider’s customer service department and ask for the specific reason why your request was denied. Most of the time, the denial is the result of a missing document. Take note of what was missing so you can work with your health care team to get the necessary documentation. 

However, if you were denied because your health insurer deems the device as “not medically necessary,” then ask the insurer what led them to this conclusion. When you’re armed with the proper definition, you can work better with your healthcare team to counter the denial.  

But if the insurer’s customer service cannot provide you with answers, ask if they have a patient advocate or an advocacy department that can help you turn the decision in your favor. 

Making an appeal

Most of the time, your physician or another health care provider will be in charge of writing the appeal. But there are other times when only you are authorized to submit a bid. If it’s the former, you wouldn’t have much to worry about except provide the necessary documentation. If it’s the latter, then you need to prepare to get the work done. You can always turn to your health care team. They have a lot of experience with the appeals process, which makes them a great resource.

We put together a checklist for you to ensure that all your bases are covered:

Plan out your appeal. Refer first to the instructions that are provided with your Explanation of Benefits (EOB). If you can’t find the instructions in the document, contact your health insurance provider as soon as possible to avoid missing deadlines.

  • Take note of the timeframe. You must work with the deadline in mind, so you don’t miss your chance to appeal.
  • You are generally allowed 1-2 appeals with the insurance company. If both are denied, check your plan and see if you’re eligible for an external appeal. 
  • Gather copies of your medical reports from your health care team to support your case.
  • Write a cover letter. This helps your insurer zero in on the necessary facts.
  • Indicate the reason why the claim was denied.
  • Quote their policy and explain why you disagree.
  •  Include a bulleted list detailing the attached documentation. This helps your insurer quickly find the necessary papers. 
  •  State your argument on why you think the claim should be paid. Of course, make sure that you have the proof that supports your argument. 

Using the steps outlined above, you can take better charge of your health whether you’re a new amputee, your ability level has changed, or you find out about new technology that can increase your independence. It’s also best to keep in mind to stay in touch with your healthcare team even after you’ve received your new assistive device. They can help you make the most out of it. 

If you have any questions feel free to leave a comment below.

 

A guide on how to get better assistive devices through your insurer

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<a href="https://amputeestore.com/blogs/amputee-life/living-better-how-to-get-better-prosthetic-devices-through-your-insurer">Living Better: How to Get Better Prosthetic Devices Through Your Insurer</a>

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4 comments


  • Hi Robert
    This article is very applicable to Medicare and their procedures. At the time of this posting Medicare doesn’t have an equivalent approval process similar to HMOs, however behind the scenes your Prosthetist and his/her staff are working overtime to make sure they have the appropriate paperwork in place before delivering your new C-Leg. Paperwork required ranges from physician notes that specify your desire to walk to your activity level to a sound letter of medical justification. If this paperwork is incomplete Medicare will decide not to cover your prosthesis. Depending upon the documents you’ve signed with your Prosthetist you may be liable if your Prosthetist is unable to get compensated.
    Thank you again for taking the time to read our blog and leaving a comment.
    Bryan P
    Amputee Store

    Bryan P on

  • I have found this to be very true. Ddealing with the provider “on yheir level” shows you pay attention and know what is happening. They are usually, my experience, more helpful when they know uuo are working to better yourself yhan being just an angry consumer. They are people and make mistakes or overlook documents. Be detailed and keep notes of those contacted and how. It will work in your behalf in the long run!

    Jim Mercier on

  • Thank you, thank you, thank you. I was just told today that I need a new leg. I will now go much better prepared to the doctor.

    Barbara on

  • I currently have a C-leg, which I have had for approx. 10 years. Next March I go on Medicare. I badly need a new C-leg/equivalent but am holding out for March when I go on Medicare. The Medicare insurance plan plus supplement will cover the cost 100%. I recently read an article regarding a crack down to the medicare approval process regarding prosthetic’s. Your article doesn’t really address medicare. Do you have any information regarding the process?

    Robert on

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