\u201cThe electronic prosthetic knee is life-changing,\u201d said Adams, who lives in Lafayette, Colorado, with his wife and two kids. Without it, \u201cit would be like going back to having a wooden leg like I did when I was a kid.\u201d The microprocessor in the knee<\/a> responds to different surfaces and inclines, stiffening up if it detects movement that indicates its user is falling.<\/p>\n People who need surgery to replace a joint typically don\u2019t encounter similar coverage roadblocks. In 2021, 1.5 million knee or hip joint replacements were performed in United States hospitals and hospital-owned ambulatory facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ. The median price<\/a> for a total hip or knee replacement without complications at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, though health plans often negotiate lower rates.<\/p>\n To people in the amputee community, the coverage disparity amounts to discrimination.<\/p>\n \u201cInsurance covers a knee replacement if it\u2019s covered with skin, but if it\u2019s covered with plastic, it\u2019s not going to cover it,\u201d said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after an airplane accident nearly 30 years ago.<\/p>\n AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthetic is determined to be medically necessary, such as to replace a body part or function for walking and day-to-day activity. <\/a>In practice, though, prosthetic coverage by private health plans varies tremendously, said Ashlie White, chief strategy and programs officer at the Amputee Coalition. Even though coverage for basic prostheses may be included in a plan, \u201coften insurance companies will put caps on the devices and restrictions on the types of devices approved,\u201d White said.<\/p>\n An estimated 2.3 million people<\/a> are living with limb loss in the U.S., according to an analysis by Avalere, a health care consulting company. That number is expected to as much as double<\/a> in coming years as people age and a growing number lose limbs to diabetes, trauma, and other medical problems.<\/p>\n Fewer than half of people with limb loss have been prescribed a prosthesis, according to a report by the AHRQ<\/a>. Plans may deny coverage for prosthetic limbs by claiming they aren\u2019t medically necessary or are experimental devices, even though microprocessor-controlled knees like Adams\u2019 have been in use for decades.<\/p>\n Cain was instrumental in getting passed a 2000 Colorado law that requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20% coinsurance payment. Since that measure was enacted, about half of states<\/a> have passed \u201cinsurance fairness\u201d laws that require prosthetic coverage on par with other covered medical services in a plan or laws that require coverage of prostheses that enable people to do sports. But these laws apply only to plans<\/a> regulated by the state. Over half of people with private coverage are in plans not governed by state law.<\/p>\n The Medicare program\u2019s 80% coverage of prosthetic limbs mirrors its coverage for other services. Still, an October report by the Government Accountability Office<\/a> found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.<\/p>\n Cost is a factor for many people.<\/p>\n \u201cNo matter your coverage, most people have to pay something on that device,\u201d White said. As a result, \u201cmany people will be on a payment plan for their device,\u201d she said. Some may take out loans.<\/p>\n The federal Consumer Financial Protection Bureau has proposed a rule that would prohibit lenders from repossessing<\/a> medical devices such as wheelchairs and prosthetic limbs if people can\u2019t repay their loans.<\/p>\n \u201cIt is a replacement limb,\u201d said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prostheses. Repossession is \u201cliterally a punishment to the individual.\u201d<\/p>\n Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his portion of the insurer\u2019s negotiated rate for the knee and foot portion of the leg but did not include the costly part that fits around his stump, which didn\u2019t need replacing. The insurer approved the prosthetic leg on appeal, claiming it had made an administrative error, Adams said.<\/p>\n \u201cWe\u2019re fortunate that we\u2019re able to afford that 20%,\u201d said Adams, who is a self-employed leadership consultant.<\/p>\n Leah Kaplan doesn\u2019t have that financial flexibility. Born without a left hand, she did not have a prosthetic limb until a few years ago.<\/p>\n Growing up, \u201cI didn\u2019t want more reasons to be stared at,\u201d said Kaplan, 32, of her decision not to use a prosthesis. A few years ago, the cycling enthusiast got a prosthetic hand specially designed for use with her bike. That device was covered under the health plan she has through her county government job in Spokane, Washington, helping developmentally disabled people transition from school to work.<\/p>\n But when she tried to get approval for a prosthetic hand to use for everyday activities, her health plan turned her down. The myoelectric hand she requested<\/a> would respond to electrical impulses in her arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she said she can\u2019t afford.<\/p>\n Working with her doctor, she has appealed the decision to her insurer and been denied three times. Kaplan said she\u2019s still not sure exactly what the rationale is, except that the insurer has questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent review organization certified by the state insurance commissioner\u2019s office.<\/p>\n A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic has ordered the hand and made the customized socket that will fit around the end of her arm. But until insurance coverage is sorted out, she can\u2019t use it.<\/p>\n At this point she feels defeated. \u201cI\u2019ve been waiting for this for so long,\u201d Kaplan said.<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\n![](\"https:\/\/fctuckerbatesville.com\/wp-content\/uploads\/2025\/01\/Prosthetic-fairness-Adams-scaled.jpg\")
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