Blue Cross and Blue Shield of Kansas asked a board certified prosthetist to review my case and address some of the issues I raised, particularly with the language 'standard' and 'deluxe.' In the end, I am still denied the microprocessor knee because “electronic items are excluded by policy language.” However, this anonymous prosthetist took them to task:
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'Deluxe' items provide function beyond the restoration of the lost body function or part. On this basis, I agree fully with the member [KFG] that there is no such thing as a ‘deluxe’ prosthesis since none come anywhere close to fully restoring the lost functions of the intact limb.
A ‘basic’ or ‘standard’ prosthesis is one that reflects the best available evidence and clinical judgment regarding those alternatives most likely to enable the person to reduce the impact of the functional losses cause by the amputation. Based on the information reviewed, I would consider the prescribed prosthesis to be a ‘standard’ device in this case.
While the denial of the electronic codes will not render the prosthesis unusable, it will clearly make it less effective in enabling normal activities of daily living. Based on the best information to date, it is to be expected that – without the electronic features – the prosthesis will be more difficult to walk with, less secure, less responsive to changes in terrain or cadence and less effective in permitting normal activities of daily living.
The fundamental problem we are all struggling with here is the archaic language of the policy and its arbitrary exclusion of electronic components from consideration.
Electronic technology has been accepted as a ‘standard’ mainstream alternative for appropriate prosthetic candidates since 1970. As the member correctly points out, it is ironic that, while her State insurance policy excludes the electronic elements of her prosthesis, she would receive this level of care if she were on Medicaid or Medicare. From a prosthetic standpoint, she would be better off to give up on working and accept Social Security Disability Income and Medicare coverage and/or to declare bankruptcy and become a Medicaid recipient.
At the present time, it is illegal in 11 states to sell policies having such arbitrary exclusions and parity laws are pending in 30 additional states. Federal legislation has been introduced in the House to make coverage at least equal to that offered by Medicare as a national requirement.
In summary, the denial of these codes must be upheld because they are specifically excluded by the policy. Exclusion of these items will result in a prosthesis that is less secure, less responsive and less effective than the prescribed ‘standard’ electronic knee.
I hope these candid responses will prove helpful in understanding all of the complex issues brought to light in this case.
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Compelling, isn’t it? What was the BCBS response? “Based on our consultant’s specific comments about this case, our consultant is unable to certify medical necessity.” I hope you're snorting with indignation.
To protect my physical and mental health I will purchase the microprocessor knee myself – a significant out of pocket expense - but I'm not giving up the fight. I’ll keep fighting for parity and will use those powerful words above to make my case. Keep fighting with me so we can make these shameful practices illegal.
Shame on the health care policy makers in Kansas!
