Taking on prosthetic insurance coverage denials state-by-state and winning!
8th November 2024
8th November 2024
Last week we sent another prosthetic insurance coverage claim denial to court and together with our patient, we won!
When we started Open Bionics we had no idea how often insurance companies would deny prosthetics claims. We’ve lost count of how many times someone who was born with one-hand, into a world designed for two-hands, has been told they do not need a prosthetic aid because they were born that way. Does anyone understand this? *slow blinks*
We’ve also lost count of how many times larger companies have told patients and our team not to fight insurance denials because ‘they’re impossible,’ ‘unlikely,’ and ‘too expensive’.
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We have been working on this fight for sometime and we’re really happy to share that our last five denials were all successfully overturned and approved for funding.
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To us this seems like short-term thinking. If O&P clinics do not challenge prosthetic insurance coverage denials there is no possibility of improvement for the people who ultimately bear the consequence of the denial; the patients.
We have to keep appealing. We have to keep improving our documentation. We have to keep encouraging patients to take to their phones and fight their providers for their coverage.
Even though we are a tiny company within the world of O&P we are committed to having a long term, positive impact. Even though we are small, we are mighty! 🦾
We have been working on this fight for sometime and we’re really happy to share that our last five denials were all successfully overturned.
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Insurance companies are not denying humans, they are denying L codes. It is up to us to work together to educate insurance companies on the impact a device can make to your life.
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We can’t communicate how thrilled the families are with the ruling in their favors. Our clinicians worked together closely to help them build and present their case. It was not easy, but it is becoming easier. If you have had an insurance denial, please work with us to convince your insurance company to approve your claim. Success comes when patients work closely with their care provider / clinician to challenge the denial.
Insurance companies are not denying humans, they are denying L codes. It is up to us to work together to educate insurance companies on the impact a device can make to your life.
These fights feel like David vs Goliath and it looks like David is making some headway. Fighting a denial is expensive for companies, and it seems like the fight is being taken up by the smaller companies within O&P. The larger companies have not been supportive and this post is also a plea to them – help us fight denials! You have far greater resources than the smaller O&P companies. Think about what progress we could make for our upper limbs patients collectively if we all challenged every denial.
“I told them, whether their decision will be in our favor or not, that the support from insurance for children who need a prosthetic(s) is lacking incredibly, and every child deserves a fair shot at being as close to “normal” as every child around them. I hope that the next Michigan family doing their prosthetic research for their kiddo isn’t met with the same gut punch denial. I’m just filled with so many happy emotions”
“The review committee commented on how eye opening this case was for them”
Read Logan’s full story of getting his Hero Arm through insurance.
Elise, you fought hard for your appeal win last week. How do you feel about it? What did it feel like to receive updates from your patient after the court hearing?
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“I had no idea what to expect. I was always told that if a code is not listed on the policy’s fee schedule (Medicaid specifically); then it is not covered. I gave into this notion until I was informed of the Federal Statute “Title 42 of the U.S. Code (Chapter 7, XIX, 1396d)” that state policies must provide all medically necessary services for members who are ages 0-20 years old. This is the law, and is true even if it is not a listed service. We have been continually advised that these claims will never get overturned and I am so grateful for this family putting in the effort with me to try to fight it. If we were successful in our fight, this family’s effort would in turn help support others like their son.
The review committee for this case talked about how “eye-opening” the denial was for them. I think this means the insurance companies are not even aware these issues are present. How can they iron out these issues unless people make some noise and bring it to their attention? If we don’t challenge the denials, they won’t know a problem exists.
Change doesn’t happen overnight and it takes consistent pressure to make movement. I am very proud to be able to help my patients fight for access to care and wins like this remind me it is worth it. My patient was thrilled after the court hearing. They were texting updates throughout and so excited.“
Emily, you recently won an appeal with your patient in Orlando – what was that feeling like? What do you think about our effort to challenge denials? What did it mean to your patient?
“My most recent appeal was a huge victory because we managed to overturn a denial that was based on an explicit policy exclusion. This took several months and multiple stages of the appeal process. I have to applaud the patient and his parents for their unbelievable patience and grit during this process. This outcome gives me so much hope for other prospective Hero Arm users. The more we keep challenging these restrictive policies, the better chances we have at broadening access to myoelectric technology.”
Dan, congrats on your recent successful insurance denial appeal in New York – how did you do it? What did it mean for your patient?
“I think The external (state level) appeal was successful because we hit it from all ends. The Dr provided additional documentation on how this would help our patient’s overall well-being and function, highlighting overuse symptoms and current struggles. Our user provided a letter from a personal standpoint on how difficult her day to day routine is and how the hero arm would help her overcome those challenges. I then provided the breakdown on how the hero arm would benefit her functionally, but more importantly, why a body powered arm would not for the activities she requested. In the external appeals, the reviewing physicians are using their personal knowledge as well as peer-reviewed research articles to make their decisions so we have to also send credible references for them to consider along with their own findings. The reviewing physicians have to cite research in their responses to justify their decisions. This process involves a lot of documentation, research, evidence, and back and forth.
My patient was very happy and kept saying that nobody had ever put in this amount of effort to help her. I’m glad we could do this for her.”
Finally, we want to thank every patient who has made an effort with us to fight their prosthetic coverage insurance denials. It is unfair that you have an additional burden to accessing potentially life-changing equipment and aids for your body. Thank you for advocating hard for yourself and your needs even when tired and demoralized. Thank you for helping us with the volume of documentation and evidence we need to submit to make the appeal strong. We’re with you, and we’ll keep doing what we can to get you the approval you need.
Are you a patient that wants to get started fighting your insurance denial right now?
Here are ways patients have successfully fought their denials in the past, try taking these actions. You can also see a guide our clinician Daniel has written about insurance coverage for bionic arms here.
