When our patient Kiersten, who has a congenital limb difference, first started experiencing overuse issues in her sound arm and in the shoulder of her affected side, she wondered if a prosthesis could help. “It was my first time asking insurance for anything like this. Both a prosthesis and, say, medication, are prescriptions, but they’re very different things a prosthetist has to have a prescription signed by your physician for your device. I struggled to get my insurance company to approve my device.”

Receiving a “no” after requesting insurance coverage of an upper limb prosthesis is something many of our patients have gone through. Yet, a very large percentage of our patients have received their prosthesis, following an appeal sent to their insurance company. What is the advice that our current patients have for our new patients or potential patients?

“Don’t let a denial deter you,” Kiersten told us in a recent interview. “Yes, it was a struggle, but I know my body and what it needs best. After speaking with my physician and my prosthetist, I was told that a myoelectric device would work best for me. I wrote letters and made a lot of calls. Being told ‘no’ by a big corporation can be scary. It made me second guess myself, like, 'They said I don’t need it, maybe I don’t?' But I kept pushing. For me, it was a great opportunity to learn how to advocate for myself. There is so much power in patient advocacy. I cannot stress that enough.”

Kiersten
Kiersten, who is a model, singer and actor.

Kiersten continued, “Sometimes it felt like a full-time job. Insurance would tell me that maybe they would approve a body-powered device, but I knew, since I had done my research, that that would only worsen my overuse issues. I persevered, and since getting my myoelectric device, those overuse issues have disappeared.”

Our patient Isaiah, who has a below-elbow amputation, would agree that patient advocacy is key. “You have to be your own advocate when it comes to prosthetic care. You have to make sure you voice what you want and your concerns when it comes to your devices and your care. It can be difficult to get what you know you need. A lot of people don’t know what they deserve. They may not be willing to push for what they need. If someone is unable to communicate their needs, then it’s going to be harder. The process of going through insurance and workers’ comp it’s not a friendly process. It’s tedious and without pushing you may end up with nothing or something that isn’t what you need. So yes, you have to be an active, on-top-of-it advocate for yourself.”

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Isaiah working with his TASKA hand.

Kiersten and Isaiah are great examples of patients with a lot of resolve, which is exactly what they needed to get the devices and prosthetic care they needed to live their lives pain free and pursue their goals. But resolve is only one part of the puzzle. The know-how is the other. That’s where our Arm Dynamics Justification, Authorization and Billing (JAB) team comes in. Their goal is to help our patients navigate the system, letting them know how to file appeals, what documentation they may need and giving advice as to when to write letters to insurance providers.

Our patient Chris, who has an above-elbow amputation, was able to get his device with the help of our JAB team. “If not for the encouragement from the team and not taking ‘no’ for an answer,” Chris told us, “I would have given up at the first denial. I am confident I would not have the prosthesis I have today.” Chris continued: “Do your research and don’t give up when insurance says no!”

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Chris with his ETD prosthesis.

There aren’t any tricks to going through the appeals process with an insurance provider. But having a team with experience on your side, who knows you and what you need, can turn that denial into an approval our team has seen it happen many times. Persistence and patient participation are key. We hope that the above stories provide motivation. Also, you never know how things will turn out when Kiersten requested a second prosthesis two years later, she was approved without any denials. “It was a completely opposite experience. The first time was emotionally draining, the second time was a breeze. I’m just really grateful to have what I need.”

If you or someone you know would like to learn more about our holistic prosthetic care and the support that our JAB team provides to our patients, please contact us. If you have your own story of navigating your insurance provider’s approval process, or if you’d like to send a message to any of the patients mentioned here, please comment below.

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