Sometimes gaining insurance approval for a prosthetic device can feel like an uphill battle—especially for those who need an upper-limb solution.
The process for gaining insurance approval for prosthetic devices typically begins with a certified prosthetist submitting a claim for coverage. For those who hope to acquire an upper-limb solution, especially functional prosthetic fingers, the process can sometimes include additional steps.
“Approval for upper in general can take longer than lower,” explains Jake Terrebonne, certified prosthetist with Hanger Clinic in Louisiana. “It probably has to do with the percent of upper versus lower. Doctors tend to see lower-extremity amputees more often.”
Just as a doctor’s experience with finger and partial hand amputations may impact outcomes, the insurance provider can also affect time, costs, and coverage. Most insurance providers will cover some, if not all, of the costs associated with your prosthesis. However, there may be limitations as to what kind of prosthesis will be covered.
For example, devices that are used for cosmetic rather than functional purposes or special prosthetic devices used for athletics may not be covered by insurance. Additionally, newer products or those that are more expensive may not be covered. The entire process can be lengthier than expected.
So, what can you do to make sure your insurance process moves along as swiftly and smoothly as possible?
Don’t be afraid to interview your prosthetist.
Make sure your goals and personalities align. You don’t have to stay with a prosthetist if you’re not comfortable. You can always ask your doctor, the manufacturer of your prosthesis, or other care team specialists for recommendations.
Once things are moving forward with your prosthetist, prepare for an initial denial from your insurance company. Don’t worry, it’s completely normal for a claim to get kicked back on the first attempt. Because most insurance companies rely on an automated system to process the initial request, they won’t know the specific benefits a device will provide. Start your appeal as soon as possible and expect to be contacted by a case manager.
The biggest thing is documentation and self-advocacy.
Insurance claim case managers are looking for proof. Be prepared to send letters, pictures, and even videos. Gather case studies, testimonials, and other evidence of successful outcomes.
“For my insurance claim, I had my surgeon and my family doctor write letters,” says Tracey Moss, who wears two MCPDrivers from Naked Prosthetics. “I flooded them with letters from the doctors, and my list of things I can’t do anymore—it helped.”
Tracey listed over 100 things she couldn’t do anymore, such as tying shoes, opening a jar, tucking in fitted sheets, and taking a picture with a non-phone camera. “Most people don’t even think about what their fingers can do—until they can’t,” she says. In Tracey’s case, her proactive proof prevented her from getting a denial, but the process was still delayed.
Jake, who has helped overturn denials, prepares by documenting as much as possible at the initial appointment. He took pictures and videos in case he’s asked by insurance companies later. Plus, he says, even if insurance doesn’t need it, the images help the manufacturer customize the device to a patient’s precise presentation.
“Find a certain grab or gesture that is specific to the patient and document it,” he advises. “Like one guy I helped, who’s a chef, he has a certain finger flexion and grasp needed to whip a skillet. And another guy, who works with tiny electrical boxes, his main use of his device is for the back and forth rotation needed to use a screwdriver. A silicone restoration would’ve broken down; he’s had a Naked Prosthetics (NP) device for 18 months and it’s great.”
“Sometimes case managers may come back with ‘Is there a cheaper option?’,” Jake explains, “and the answer is simply, no there is not. And then you pull out your documentation as to why.”
You can help your prosthetist by making a list of your daily activities that are affected by your amputation(s), as well as your goals. Jake emphasizes: “Not only state why and how the NP device benefits, but why nothing else compares.”
Be patient and persistent.
Sometimes a patient has to be the one who advocates the most. This can be trying, exhausting, and frustrating. You don’t have to do it alone. Jake advises asking for a 20-minute sit-down with both your prosthetist and your doctor. Family, friends, and co-workers can also write letters of support. Don’t give up! Advocating for yourself or your patient will help set the precedent for future amputees.
You may experience several insurance denials before approval, resulting in what is called a peer-to-peer review. This means an outside, objective professional will make the final approval decision. This is typically a phone conversation between a physician at an insurance company (the one that’s refusing to pay for services) and the patient’s provider who is requesting your devices. Once a case reaches this level, and the outpouring of proof has been gathered and presented, the approval is typically a success.
Because NP uses such advanced technology, your prosthetist may use billing methods that require additional documentation. If you or your prosthetist would like support during the reimbursement process, please check out Naked Prosthetics’ resource page and call Customer Care at 360-915-9724 or toll-free at 888-977-6693.
For tips on contacting your insurance company, check out this list from Amputee Coalition. To help find a prosthetist who is good fit, check out these questions to ask when choosing a prosthetist.
