Prosthetic insurance coverage disparities persist despite legal protections

Editor's Note

Health insurance coverage of prosthetics remains inconsistent and often inadequate, KFF Health News reported January 6. As a result, many patients face coverage denials due to claims of lack of medical necessity or high costs despite significant advancements in prosthetic technology, such as microprocessor-controlled knees and myoelectric hands.

An estimated 2.3 million Americans live with limb loss, the outlet reports—a number expected to double in coming decades due to aging, diabetes, trauma, and other conditions. However, fewer than half of these individuals are prescribed prostheses, with coverage denials often citing experimental status or insufficient necessity, despite decades of proven utility for devices like microprocessor knees.

The article cites cost as one major hurdle. Even with insurance, patients often face substantial out-of-pocket expenses. For example, Medicare covers 80% of prosthetic costs, but only 30% of beneficiaries who lost a limb in 2016 received a prosthesis within three years. Private plans vary widely, with many imposing caps or excluding advanced prosthetics.

State-level "insurance fairness" laws in about half the US aim to align prosthetic coverage with Medicare standards or ensure access to prostheses for sports, but these laws only apply to state-regulated plans, KFF reports. Over half of Americans with private insurance are in plans exempt from such regulations, leaving a significant gap in coverage.

The full article offers additional context, including testimony from experts and patients, as well as details on appeals processes and the impact of proposed federal rules.