Anthem, a company that provides health insurance, was recently sued for refusing to provide coverage for some prosthetic devices for some of its customers. The plaintiffs are seeking to turn the lawsuit into a class action and to force the company to pay for the devices. The devices that are being excluded are microprocessor-controlled devices, which are prosthetic limbs controlled by a computer instead of by the body.
Anthem has issued medical policies to administer their claims. The plans specifically exclude coverage for any devices or services that are not “medically necessary” or are “investigational”. The insurance plans specifically label microprocessor-controlled knee prostheses as “not medically necessary” and therefore not covered unless the following four criteria have been met:
- The individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology and to allow for faster than normal walking speed; and
- The individual has demonstrated the ability to ambulate faster than their baseline rate using a standard swing and stance lower extremity prosthesis; and
- The individual has a documented need for daily long distance ambulation and variable rates; and
- The individual has a demonstrated need for regular ambulation on uneven terrain or regular use on stairs.
The lawsuit alleges that that the criteria set forth by the company are erroneous and unreasonable. The lawsuit is asking that Anthem be required to reimburse the plaintiffs for their artificial limbs, as well as to pay for the limbs going forward.
Call me, Conal Doyle, if you have had your claims for a prosthetic limb denied. I can help. Call me today at 310-385-0567 to learn more or to schedule a free consultation on your case.