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Insurance, Prosthetics, and the Boston Marathon Bombings

Posted on Apr 24, 2013 by Ailee Slater ()  | Tags: Amputee Coalition, amputee insurance, amputees, Boston Marathon Bombings, obamacare, prosthetics

Of the 264 people injured in the Boston Marathon Bombings, at least 13 have suffered the loss of all or part of a limb. Already there have been stories of perseverance and strength - one husband and wife, standing together at the finish line, both lost the lower part of their left legs. They are recovering as well as can be expected, and the experience of these and other amputee survivors has brought the issue of prosthetics and health insurance to the forefront of health care news.

In a recent article about the challenges faced by marathon bombing amputees, the Boston Globe spoke with patients and doctors about the effects of suddenly losing a limb. Besides expected difficulties, such as getting through the surgeries and pain, and re-learning how to perform everyday tasks, amputees must also contend with the process of getting a prosthetic limb. Under some insurance policies, a patient will wait five to six weeks for the limb; other types of coverage, however, may necessitate a waiting period of nearly one year.

When it comes to prosthetics and insurance, most people are not even aware of the extent to which a prosthetic device is covered under their current policy. The thought of an amputation seems an impossible idea, and so the eventuality is not considered when purchasing an insurance plan. Coverage of prosthetics can vary widely from one insurer to the next.

One case of a patient who experienced a surprise amputation, and resulting conflict with her insurance company, was reported on by ABC News in 2009. The story centers around a 23 year old woman, Susan Bailey, who contracted E. coli, and became severely ill. The infection spread to her legs, which had to be amputated. When Bailey recovered, she was given a pair of prosthetics through her existing insurance coverage. However, these prosthetics were not ideal - Bailey's legs had been amputated above the knee, and her prosthetics were a short variety, designed for below the knee amputees.

Susan Bailey attempted to use her short prosthetics, but soon discovered that performing normal tasks, or even maintaining balance while standing, was a near impossibility. In researching alternatives, her doctors found a new type of prosthetic called C-Legs. These prosthetic legs include a computer chip to make walking easier, and to adjust naturally to the wearer; C-Legs are recommended in particular for above the knee amputees.

However, when Bailey contacted her insurance company about the possibility of procuring C-Legs, she was informed that her policy would not cover the purchase. According to the insurer, C-Legs were an experimental product, and did not come under the coverage umbrella of  medical necessity. Bailey filed two appeals, and was each time denied.

The situation with Susan Bailey certainly calls attention to the insurance hurdles which an amputee can face. Luckily for Bailey, she finally got her C-Legs - after appearing on the television program Good Morning America, viewers donated the $100,000 USD she needed to purchase the prosthetics.

Besides morning TV, advocacy groups such as the Amputee Coalition can also help patients who have lost a limb, and are unsure about their insurance coverage. For example, the Amputee Coalition recently published a press release aimed at better informing amputees about coverage upon joining Medicare. Because Medicare will often look to the records of a primary care (rather than the records of a specialist prosthetics doctor), amputee patients must be careful that a discrepancy in the records of these two doctors doesn't result in less Medicare coverage.

To help amputees avoid this Medicare pitfall, the Amputee Coalition offers a letter which patients can print out and take to their primary care doctor, encouraging the doctor to write records in a particular manner so that the patient can better document needs for prosthetic care or devices.

The Amputee Coalition has also taken an interest in President Obama's Affordable Care Act; specifically, the coalition has been lobbying to make sure that prosthetic devices and special orthotics are included in every state's list of Essential Health Benefits. According to Obamacare, any insurance policy sold on a state exchange must include certain Essential Health Benefits, such as preventive care or ambulatory services. Along with other amputee advocacy groups, the Amputee Coalition believes that access to prosthetics should be included on all insurance plans as an Essential Health Benefit.

In fact, Obamacare has already helped amputees by prohibiting non-grandfathered insurance plans from charging more to any policyholder based on a pre-existing condition. In the future, amputee should have access to more affordable insurance, regardless of their having lost a limb.

Advocacy groups are also hopeful with more competition on the market, insurance policies will begin to offer better coverage of prosthetics. A problem at the moment is that although a policy may cover the cost of a prosthetic limb one time, upgrading the prosthetic is often not a possibility, unless paid for entirely by the patient. This issue is especially pressing for amputees who are physically active, and wear down their prosthetic limbs quickly. Moreover, with frequent improvements in the understanding and technology of prosthetics, patients who aren't able to upgrade to a new limb are missing out on all of this medical advancement.

Still, with such promising gains in prosthetic technology, as well as more awareness about amputees and their particular health care needs, the situation of insurance and prosthetics will surely improve in the future.

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