Getting Your Prosthetic Device: Your Guide to the Appeals Process

No matter what kind of insurance plan you have, your request for a prosthetic device might be initially rejected. It is a fairly standard occurrence that an insurance carrier will deny an authorization claim when first submitted. Such a setback may make a patient so discouraged that they might not appeal. That is a mistake. The downside to appealing is only that it is a hassle. The upside is a prosthetic device that can make your home and work life much easier and could even help you be healthier.

The purpose of this article is not to explain all the steps for an appeal process. It is rather to let you know what is in store for you and discuss what you can do to make an appeal approval more likely. You do not need to worry about the nitty-gritty details when you work with our Arm Dynamics team members to receive your prosthetic care — we have a task force within our Justification, Authorization and Billing (JAB) team that specifically addresses appeals.

Your first appeal begins after your initial denial. We will walk you through those specific steps, but one thing we can recommend is to advocate for yourself. We can fill out and help you fill out all the necessary forms, but we have found that success comes most often to those who go above and beyond. Below are some suggestions:

• Write a compelling letter to the insurance company, describing all the ways that you experience challenges in your daily life. Try to outline what a typical day looks like, and what tasks you find difficult or impossible (we can show you past examples and walk you through that letter creation).
• Ask your doctor to write a letter to your insurance company. In it, they should also describe any challenges that you are having on a daily basis, and anything like pain, scarring or thin skin. These descriptions should be backed up in office notes. In addition, if you are having any overuse issues (carpal tunnel, rotator issues), it helps if the physician includes that information. Be sure they include any information about any diagnostic testing they have performed on you or surgeries you have had.
• Give your insurance company a call and ask them what else you can personally do to help win the appeal.
• If your insurance is self-funded through your employer, get your employer involved, to see what they can do to help.

Your goal with your outreach to the insurance company is two-fold: one, educate the insurance employees (many of them are unaware of the reasons why, say, a congenital amputee may need a prosthetic device after years of not having one); and two, let them know that you are an individual in need, that you are a person, not just a number.

If a formal appeal is denied, our JAB team moves forward with second level appeals, peer-to-peer reviews, and request for an Independent Review (IRO).

Some of our potential patients that we have worked with eventually exhausted all the above options. Every case is different, so if you reach the end of the process we’ve described so far, we will go over any other options you may have. Some of our patients who have exhausted their appeals process ask us about switching insurance companies, or which carrier they should switch to. We tell them that it’s really more about the plan that the patient has than the carrier. If you do consider switching insurance carriers, you should review the plan provisions first: does their plan limit prosthetic options; does that plan limit you to one prosthetic device; what are their in/out of network out-of-pocket limits; and are their current physicians under the plan?

If you would like to learn how our clinical team and our JAB team can help you get a prosthetic device that will make your life easier, please contact us. If you would like to tell us and your peers about your own appeals process, please comment below.

For more Arm Dynamics articles, see related resources here:

• How Our Justification, Authorization and Billing Team Helps Advocate on Your Behalf
• How to Advocate for Yourself When Dealing with Your Insurance Provider
• Overuse Issues for People with an Upper Limb Difference
• Advocating for Yourself When You Need an Upper Limb Prosthesis
• Getting Back to Work After an Upper Limb Amputation