How Our Upper Limb Specialists Work with Physicians to Overturn Insurance Denials

As soon as the letter from the insurance company arrived, arm prosthetist Jonah Rhymer, from our Chicago, Illinois clinic, knew what it meant for his patient. A 10-year-old who needed a bionic arm had been denied coverage. But unlike most insurance denials, this appeal process would be different, because neither Jonah, nor the child’s family would be allowed to appeal the decision.

“They denied my patient a bionic arm because it was deemed ‘not medically necessary,’” he said. “We were not allowed to appeal it. They wouldn’t let me or the patient get involved.” The insurer labeled the device “investigational,” even though our bionic arms are FDA approved and supported by current research, not to mention over 1,000 people wear them. That left only one path forward: a peer-to-peer meeting between the prescribing physician and a physician employed by the insurance company to determine medical necessity.

“It all comes down to a Zoom call,” Jonah explained. “They set up a meeting and they had a call about the patient.” No prosthetist in the room. No parents. Just two physicians, one explaining the medical need for a prosthesis and one deciding whether it would be covered. “It feels very high stakes,” he said. “If the doctor did not have the preparation or the words to explain why, it probably would not have gone anywhere.”

Jonah assumed the reviewing physician knew very little about upper-limb prosthetics, because most don’t. “They don’t have the background that we have,” he said. “They probably don’t even know more than, ‘It’s a bionic arm,’ and that’s it.” He also understood the pressure they face. “They have fifteen minutes with the patient. They do not want a complicated explanation.”

Jonah set out to build the appeal case himself. When the physician’s office asked for help, he was ready with a short list of bullet points that the doctor could use during the call. “I highlighted the reason for the denial and why it was wrong,” he explained.

Jonah’s good at keeping the language simple. His notes explained how the child struggled at school with scissors, textbooks, rulers, binders and lunch trays. At home, tying shoes, buttoning shirts and cutting food required extra help. After long school days, the child was beginning to report soreness in his shoulder. Rhymer also explained why basic or single-grip devices would not meet their needs and how a multi-grip myoelectric device would help him work more safely and independently.

“I put it as simply as I could so that when the physician was in the peer-to-peer meeting, they had concise talking points they could reference,” he said. “I needed it in her language so she could feel comfortable.”

He organized the packet with at-a-glance headers. “When she was on the call, she could scan the note and see exactly what she needed to talk about,” Jonah said. “It simplified it for her.”

The document included clinical need, medical necessity, relevant research and the outdated nature of the insurer’s policy. Jonah also showed that during a trial session, the child demonstrated strong, reliable EMG signals and was able to operate a dual-site myoelectric system.

After he submitted the packet, he waited. He was not invited to the meeting and did not know when it would happen. Days later, an update appeared. “I just got an overturned denial,” he said. “They approved it.” He checked the file to confirm which case it was. “Then I saw that it was the peer-to-peer case he had been working on. I thought, ‘That is great. It went through.’ It worked.”

Across our clinical teams, this outcome is becoming more common. Clinician Emily Shannon at our Orlando, Florida, clinic said many people assume a denial is final even when it is not. “Some people call their insurance or had a previous provider try, and they think it will not be covered,” she said. “I am always a little skeptical of that. You never know what the last provider tried. Did they get strong notes from the doctor, and did they go through every level of appeal possible?”

Emily is always open to try again. “If the patient is willing to let us try, I prefer that,” she said. “I cannot promise it will go their way, but I can promise we will go as far as we can.”

That persistence has produced measurable results. We overturn close to half of all insurance denials submitted for appeal. This rate is nearly 30 percent higher than national averages. “Once we got a few appeals approved, we had a precedent,” Emily explained. “We have learned a lot as we have gone through this process.”

For families, the insurance process can feel confusing and discouraging. Behind each of our approvals is a clinician who has reviewed the policy language, gathered research, documented functional needs and prepared to clearly and accurately address the denial during a review.

“The more I can do for that physician, the better results we get,” Jonah said. “They are checking boxes. If you miss a box, you get a denial.”

This time, his preparation made all the difference. A child who had been told he did not need a bionic arm is now approved to receive one.

“It worked,” Jonah said. “That is what matters.”

If you have been denied coverage for a bionic arm before, our clinicians can review your case, explain your options and support you during the appeal process. Schedule a free consultation with your nearest certified upper-limb specialist today.