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My Insurance Company Says My Prosthetic Limb Is Not “Medically Necessary.” Is That Legal?

Insurance guidelines on prosthetic limbs are very complicated. Each insurance company has its own rules about what prosthetic devices are covered and what devices are not. The rules depend on the type of device, the limb which has been impacted, and the patient’s level of rehabilitation potential, which is determined by the physician and the prosthetist.

Each insurance company defines what is medically necessary differently, but generally it means a health service or treatment that is mandatory to protect and enhance the health status of a patient, and could adversely affect the patient’s condition if not used. In general, most basic prosthetic devices could be considered medically necessary.

However, often prosthetic devices that could enhance a patient’s quality of life are considered by an insurance company as conveniences and they aren’t covered. Other devices that are new may be considered experimental and may not be covered. For example, some insurance companies will not cover a “water leg”, that would allow a person with a lower limb prosthetic to shower, claiming that it’s not medically necessary. For other people with a certain level of function (either high or low), prosthetics are not considered medically necessary by insurance companies.

Generally, if an insurance claim was denied because of lack of medical necessity, the patient should appeal within six months of the claim being denied. The patient may seek additional documentation from other professionals who believe that the prosthetic is medically necessary.

In many cases, the insurance company is acting in bad faith and may believe the patient won’t pursue the matter any further. It’s often necessary to sue the company for payment, which can result in not only coverage for the limb, but also monetary damages for the amputee. To learn more, call Conal Doyle, amputation attorney. He is not only an attorney, but also an amputee, and is passionate about helping other amputees get the compensation they deserve. You can reach him at 310-385-0567.

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