By Sherri Edge
Today’s shifting health insurance market is a source of concern and frustration for many Americans. Even while paying expensive premiums, millions of policy-holders are also hit with high deductibles, out-of-pocket maximums, and unexpected policy exclusions. For people with upper-limb prostheses, outdated medical billing codes that don’t address newer prosthetic options create an additional challenge in getting insurance claims authorized. Instead of being approved for the care they need, patients can face insurance denials, lengthy delays in receiving prosthetic care, and restrictions in provider choice.
Over the past ten years, dramatic advances in upper-limb prosthetic technologies have increased the cost of care. Diane Duran, manager of justification, authorization, and billing at Advanced Arm Dynamics (AAD), says these advances remain widely unacknowledged by Medicare and Medicaid, private insurers, some state workers’ compensation commissions, and the U. S. Department of Veterans Affairs. Components like multiarticulating hands, wrist rotators, and activity-specific devices have been on the market for years but are still categorized by insurance carriers as investigational, experimental, or not medically necessary.
“We put a tremendous amount of effort into educating payers about advances in upper-limb prosthetic care and the associated costs,” Duran says. “At least half of the estimates we submit to private insurers are going to get an initial denial. If it’s for a myoelectric device, especially one with an individually articulating digit, 80 to 90 percent of those are going to be denied straight off.”
Duran and her team of eight authorization specialists are dedicated to the challenging task of getting patient care services approved in a timely fashion. When conversations and detailed explanations aren’t enough, the justification team, along with the prosthetist and therapist who evaluated the patient, develop a formal appeal. Duran says a successful appeal often includes patient self-advocacy. “When a patient is willing to stand up for their rights and participate on a phone call with the insurance company, the odds of overturning the denial go way up.”
If a formal appeal is denied, Duran’s team moves forward with second-level appeals, peer-to-peer reviews, requests for an independent review organization (IRO), or involving the state insurance commissioner.
When Patients Win
Max Okun, who has a congenital elbow-disarticulation limb difference, is achieving his goals with a custom-designed, activity-specific prosthesis. He’s in the gym every day, building strength and stamina through an intense fitness program that would be impossible without his prosthesis.
In June 2013, Okun came to AAD for a comprehensive prosthetic evaluation. He had symptoms of overuse in his right arm and severe low back pain. An authorization request for a new prosthesis was submitted to his insurer, and a denial was returned three months later.
“The denial stated the patient had no out-of-network benefits,” Duran says. “We appealed with more detailed prosthetic information and letters from his mom and his previous prosthetic provider, who recommended Max work with an upper-limb prosthetic specialist. We received approval [in] September 2014.”
Okun was fitted with an adjustable-compression socket system that allows him to control the amount of socket compression by turning a dial. A unique hinged elbow is another key feature of the prosthesis.
“Getting an initial denial meant the fitting for my new prosthesis was delayed for more than a year. That was very frustrating,” Okun says.
“Now I can use weight machines, do bench presses, pretty much anything. My muscles are symmetrical, and my back pain is gone.”
Kassidy Prestenbach’s experience illustrates that even patients faced with quadruple limb loss are subject to denials and delays. Nine weeks after her daughter was born, Prestenbach developed toxic shock syndrome that turned into septic shock and multiple organ failure. Ultimately, she lost both legs below the knee, her left hand through the palm, and the top portion of her right fingers.
Prestenbach sought specialized multidisciplinary care for her upper-limb prosthetic needs and was evaluated by AAD in June 2016. Her insurer issued a denial for the recommended prostheses based on lack of medical necessity and stated there were other prosthetic devices available that would meet her needs. After a peer-to-peer review, the denial was overturned and an in-network exception was authorized. In September 2016, Prestenbach received a passive partial-hand prosthesis with multipositional locking digits and a spring-loaded thumb. One month later, she received high-definition, custom-silicone partial fingers for her right hand. Training with an upper-limb clinical therapy specialist was a key aspect of her prosthetic care.
“I have three children, and they need a mom,” she says. “I want them to know that no matter what life throws at you, you don’t give up. You push forward. You persevere. You don’t let anything stop you.”
For Duran and her team, overturning denials and helping patients like Okun and Prestenbach thrive is a passionate mission.
“When approvals come in, we hoot and holler, and sometimes there are tears,” Duran says. “We celebrate our victories together, because it takes all of us to get there.”