Sunday, September 21, 2008
Saturday, September 13, 2008
Shameful Practices
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:
***************
'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.
***************
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!
***************
'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.
***************
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!
Sunday, August 31, 2008
A few more suggestions
Congressman Dennis Moore has offered to look into this and I thought it would be nice just to say, "Thanks." I've included a link to his office. He only accepts email from KS constituents, but you can drop a little "Thank you" note in the mail to his Overland Park office if you don't live in KS.
Also, Governor Sebelius seems to be a compassionate and caring person. Perhaps a copy of your letter to KS HCC might make her aware of the situation for her state employees. You can write her here.
I'm being denied out of ignorance - a lack of understanding about the kinds of components and what they do. All they see is the bottom line which usually means money. Nonetheless, the bottom line is still about the disparity between Medicaid and State Employees and the Governor needs to be made aware that her State Employees with limb loss are under served - POLITELY made aware.
Also, Governor Sebelius seems to be a compassionate and caring person. Perhaps a copy of your letter to KS HCC might make her aware of the situation for her state employees. You can write her here.
I'm being denied out of ignorance - a lack of understanding about the kinds of components and what they do. All they see is the bottom line which usually means money. Nonetheless, the bottom line is still about the disparity between Medicaid and State Employees and the Governor needs to be made aware that her State Employees with limb loss are under served - POLITELY made aware.
Monday, August 25, 2008
How you can help
I've been told to write the KS Health Care Commission if I want them to change their policy. If it's a letter they want, then let's get them some letters! The instructions are below. Here's the suggested letter, but write whatever you want. You can be as passionate as you like, but PLEASE - be polite!
Next, take a moment to check the prosthetic parity law in your state by going to the Amputee Coalition of America website. If your state has not passed a prosthetic parity bill, please send a letter (scroll to the bottom of the ACA link) to your state and/or federal representatives. The federal bill is House Resolution 5615. Senator Senator Elizabeth Dole of North Carolina is considering sponoring a senate bill. Please encourage her and don't forget this is an election year.
Next, take a moment to check the prosthetic parity law in your state by going to the Amputee Coalition of America website. If your state has not passed a prosthetic parity bill, please send a letter (scroll to the bottom of the ACA link) to your state and/or federal representatives. The federal bill is House Resolution 5615. Senator Senator Elizabeth Dole of North Carolina is considering sponoring a senate bill. Please encourage her and don't forget this is an election year.
Giving "A Leg Up"
In the world of horses, giving someone “a leg up” has meant taking just a moment to give someone a boost up on their horse – so they can take over from there.
Taking a minute now to give Kathleen a leg up will help her retake charge of her own life and will subsequently benefit other amputees.
Instructions: Copy/paste the sample letter and personalize before printing and mailing – it might be just a short line about how you know Kathleen, or something special you know about her or how she has helped you. (Traditional paper and stamp letters have a very personal impact.) Remember to delete the red “insert here” sentence.
Thank you for taking the time to give Kat “A Leg Up”.
Taking a minute now to give Kathleen a leg up will help her retake charge of her own life and will subsequently benefit other amputees.
Instructions: Copy/paste the sample letter and personalize before printing and mailing – it might be just a short line about how you know Kathleen, or something special you know about her or how she has helped you. (Traditional paper and stamp letters have a very personal impact.) Remember to delete the red “insert here” sentence.
Thank you for taking the time to give Kat “A Leg Up”.
Sample Letter to KS Health Care Commission
(Insert Date)
Duane A. Goossen, Chair and Secretary of Administration
Kansas Health Care Commission
Room 900-N, Landon State Office Building
900 SW Jackson Street Topeka, KS 66612
Dear Mr. Goossen,
I am writing on behalf of Dr. Kathleen Gustafson, a state employee at Kansas University Medical Center. (Insert your personalized association with Kat here)
Dr. Gustafson was advised to write to you and ask that you reconsider the policy that refuses to cover a prosthetic microprocessor knee. Current policy considers the knee to be "deluxe" and therefore, a non-covered item. Concerned that Dr. Gustafson’s single voice may not be heard, I am writing to plead her case.
Prosthetists, the FDA, CMS/Medicare, AAOP, the VA, and over 150 insurance companies have recognized and accepted microprocessor-controlled knees as a standard level of prosthetic treatment. They have been used in thousands of above knee amputees - since 1997 in Europe and Canada and 1999 in the United States. Further indication of acceptance of microprocessor-controlled knees is Medicare’s assignment of L-Codes L5847 and L5989 in January 2002, the code L5848 in January 2003 and the code L5846 in January 1996. Research and patient reports show the microprocessor knee to be superior to simple hydraulic knees with improved patient function and mobility, fewer falls and injuries and less wear and tear on the sound limb.
Microprocessor knees are also standard of care for KS Medicaid recipients. Why is the standard of care different for KS State Employees? Dr. Gustafson is a valued employee of the State’s premiere medical and research center and her mobility is essential to her job and highly active lifestyle. Yet, the ability to walk normally, without assistance, is considered a luxury? Please reconsider and change this policy.
Sincerely,
Your name and address
Duane A. Goossen, Chair and Secretary of Administration
Kansas Health Care Commission
Room 900-N, Landon State Office Building
900 SW Jackson Street Topeka, KS 66612
Dear Mr. Goossen,
I am writing on behalf of Dr. Kathleen Gustafson, a state employee at Kansas University Medical Center. (Insert your personalized association with Kat here)
Dr. Gustafson was advised to write to you and ask that you reconsider the policy that refuses to cover a prosthetic microprocessor knee. Current policy considers the knee to be "deluxe" and therefore, a non-covered item. Concerned that Dr. Gustafson’s single voice may not be heard, I am writing to plead her case.
Prosthetists, the FDA, CMS/Medicare, AAOP, the VA, and over 150 insurance companies have recognized and accepted microprocessor-controlled knees as a standard level of prosthetic treatment. They have been used in thousands of above knee amputees - since 1997 in Europe and Canada and 1999 in the United States. Further indication of acceptance of microprocessor-controlled knees is Medicare’s assignment of L-Codes L5847 and L5989 in January 2002, the code L5848 in January 2003 and the code L5846 in January 1996. Research and patient reports show the microprocessor knee to be superior to simple hydraulic knees with improved patient function and mobility, fewer falls and injuries and less wear and tear on the sound limb.
Microprocessor knees are also standard of care for KS Medicaid recipients. Why is the standard of care different for KS State Employees? Dr. Gustafson is a valued employee of the State’s premiere medical and research center and her mobility is essential to her job and highly active lifestyle. Yet, the ability to walk normally, without assistance, is considered a luxury? Please reconsider and change this policy.
Sincerely,
Your name and address
Monday, August 11, 2008
Disparity in Action
KS Health Policy Authority weighed in again and said that they will provide me with a prosthesis that is both medically and functionally necessary, no dollar limit, as long as it doesn't contain "electronic components." That's like saying, "We'll provide you with any car you need to drive to work, pick any car on the lot! Just pick one with no motor." When asked why it's denied the answer is the same, "Because it's electronic." Yes...but WHY? "Because it's electronic." Reminds me of my mother 50 years ago..."Because I said so."
I can understand adopting a policy and sticking to it, but here's the sticky wicket -
Not only do state employees fall under the umbrella of KHPA, but so do KS Medicaid recipients. Of course, since we all fall under the same policy, the rules apply to all. Right? Wrong again. KS Medicaid recipients, under the KHPA Policy, can, and do get the prosthesis along with the electronic components. KS State employees cannot.
So here we are again. My quality of life is decided by KHPA where disparity is openly practiced. Don't think for a minute that I'm saying that KS Medicaid recipients aren't entitled to full prosthetic coverage - that's not my point. The point is that KS State Employees should be afforded equal coverage.
I can understand adopting a policy and sticking to it, but here's the sticky wicket -
Not only do state employees fall under the umbrella of KHPA, but so do KS Medicaid recipients. Of course, since we all fall under the same policy, the rules apply to all. Right? Wrong again. KS Medicaid recipients, under the KHPA Policy, can, and do get the prosthesis along with the electronic components. KS State employees cannot.
So here we are again. My quality of life is decided by KHPA where disparity is openly practiced. Don't think for a minute that I'm saying that KS Medicaid recipients aren't entitled to full prosthetic coverage - that's not my point. The point is that KS State Employees should be afforded equal coverage.
Saturday, July 26, 2008
Why I'm here
Since losing my leg above the knee in October 2007, it seems the world is filled with heroic and inspirational examples of amputees that defy all odds. Fitted with modern, high tech components, they are no end of inspiration. Oscar Pistorius can compete in the Olympics, Sarah Reinertsen is the first woman amputee to compete in the Ironman and commercials show her stepping out of a luxury car for a run in the park. An amputee walked down 70 flights of stairs to escape the World Trade Center thanks to his microprocessor knee. Ronan Tynan, a bilateral amputee, is an equestrian and world class tenor. Molly the Pony survived hurricane Katrina only to be attacked by pitbulls and lost part of a front leg but now gets around on an equine prosthesis and is an inspiration to others. Iraq war veterans are undoubtedly the most visible example of limb loss and are probably doing more to draw attention to the current state of the prosthetic industry. The industry has had to meet the demand of these young men and women who want, and deserve, to be restored to their former active lifestyles. When faced with making a choice to amputate my badly damaged and irreparable knee, I studied all of these examples of extraordinary amputees getting on with their lives, running, jumping, riding, swimming, cycling, even singing! Their ability gave me courage and confidence that I would be fine.
How did I get to this place in life? I had a birth defect as a child that resulted in a non-union fracture of the tibia – the big bone below the knee. At age 11, there were no options and my parents discussed amputation with me. I saw it as a ticket out of jail and I was right. As a below knee amputee, the world was mine for the picking. I knew no limitations. I was warned by my doctors that, “when you get older that knee will give you trouble.” They were right. I got older and my knee blew up after a particularly bad fall.
After the surgery, I awoke to a very different world. I was no darling of the media, just an average, 54 year old scientist who needed a prosthesis, working for the State of Kansas. I wasn’t planning on running a marathon, I just needed the components that could return me to where I was functionally before the accident. My insurance covers a temporary and a permanent prosthesis. The temporary prosthesis is just that – a temporary, bare bones prosthesis that gets you up and walking again. There are essentially 3 parts to an above knee prosthesis: 1) the socket that fits over the residual limb (the part that’s left) which must fit like a glove or you have no control over 2) the knee, which can range from a simple hydraulic knee to a microprocessor knee depending on your functional demands, and 3) the foot, which can range from a simple, low-heeled walking foot, to a foot that adjust to different heel heights, to a running blade. The residual limb will shrink after amputation, a normal process, that requires several new replacement sockets to maintain fit. I was fitted with my temporary prosthesis in December 2007.
For most of January and February I adjusted to learning to walk again. There was pain from the amputation, I was not confident that the hydraulic knee would work and I was shrinking out of the socket at light speed. By March, a new socket was required. Gaining the control with the new socket made a difference and I was finally able to get rid of the crutches and wheelchair. Inspired that I could now walk in a straight line with no support, we began the process of planning for the permanent prosthesis.
First I underwent an activity assessment. While I’m no high-profile athlete, I’m no slough-off either. I used to walk about 2 miles a day across campus. I lift weights, kayak, ride horses, cross-country ski, hike, hunt and fish – if I can’t be outdoors with my horses and dogs I see no point in living. Physical fitness is a priority and losing a leg is a small obstacle as far as I’m concerned. After all, if Sarah Reinertsen can do the Ironman, I can do what I want to do, right? Sorry, but that’s wrong. Who determines the limits on my physical ability? Not me, not my physicians, not my prosthetist, but my insurance company.
The administrators of my insurance contract considers the components necessary to build my permanent prosthesis and meet my activity level to be “Deluxe” and therefore, not covered. Wrap your head around that word. I see luxury items as yachts, maybe a Mercedes, a Rolex watch. A “deluxe” prosthesis? Is it gold-plated, fur-lined and diamond encrusted? Hardly! I don’t need a “deluxe” prosthesis, I just need to walk and do the things I do.
As a matter of fact, the prosthetics industry has no basic, standard or deluxe legs on the shelf. Each prosthesis is matched to the wearer’s activity level. A knee designed for high activity and sports will not be suitable for an 85-year old grandmother and Grandmother’s knee won’t help the athlete ski down the mountain. When did limbs cross the boundary of being an essential part of our body to luxury options?
The dirty secret is that there is no prosthetic parity. While the Veteran’s Administration, Medicare and Medicaid cover microprocessor components, many private insurance companies do not. It’s up to the individual insurance companies or plan administrators to determine coverage, and thus your quality of life. Some put a cap on the price, usually a ridiculous amount that wouldn’t pay for a big toe. Others give you “one limb per life” which leaves me asking, “How many lives do I get?” Others consider a prosthetic limb to be “cosmetic.” If that were the case, I should be able to get a face-lift, breast implants and a leg from my local plastic surgeon! Ten states have now passed prosthetic parity laws which require insurance companies to cover prosthetics the in the same manner as they cover other medical procedures and devices. Missouri is in the process and Kansas currently has no existing legislation. A Federal Prosthetic Parity bill was introduced on March 13, 2008 (House Resolution 5615).
I find it incredibly ironic that I work for the State of Kansas at the premiere medical and research facility, yet I am not afforded the same prosthetic coverage as a patient with Kansas Medicaid or a Kansas veteran. So, I decided to fight. After 4 months of appeals and documentation that the prosthesis is medically necessary and that my functional level meets and exceeds those needed to operate the prosthesis, I’ve been told that I’ve exhausted my appeals and that “We’re sorry there wasn’t a more favorable outcome for you.” Well, I’m sorry too. I’m probably sorrier than they are. As much as I hate the public eye, I’ve been complacent too long.
This is the beginning of my quest for prosthetic parity.
How did I get to this place in life? I had a birth defect as a child that resulted in a non-union fracture of the tibia – the big bone below the knee. At age 11, there were no options and my parents discussed amputation with me. I saw it as a ticket out of jail and I was right. As a below knee amputee, the world was mine for the picking. I knew no limitations. I was warned by my doctors that, “when you get older that knee will give you trouble.” They were right. I got older and my knee blew up after a particularly bad fall.
After the surgery, I awoke to a very different world. I was no darling of the media, just an average, 54 year old scientist who needed a prosthesis, working for the State of Kansas. I wasn’t planning on running a marathon, I just needed the components that could return me to where I was functionally before the accident. My insurance covers a temporary and a permanent prosthesis. The temporary prosthesis is just that – a temporary, bare bones prosthesis that gets you up and walking again. There are essentially 3 parts to an above knee prosthesis: 1) the socket that fits over the residual limb (the part that’s left) which must fit like a glove or you have no control over 2) the knee, which can range from a simple hydraulic knee to a microprocessor knee depending on your functional demands, and 3) the foot, which can range from a simple, low-heeled walking foot, to a foot that adjust to different heel heights, to a running blade. The residual limb will shrink after amputation, a normal process, that requires several new replacement sockets to maintain fit. I was fitted with my temporary prosthesis in December 2007.
For most of January and February I adjusted to learning to walk again. There was pain from the amputation, I was not confident that the hydraulic knee would work and I was shrinking out of the socket at light speed. By March, a new socket was required. Gaining the control with the new socket made a difference and I was finally able to get rid of the crutches and wheelchair. Inspired that I could now walk in a straight line with no support, we began the process of planning for the permanent prosthesis.
First I underwent an activity assessment. While I’m no high-profile athlete, I’m no slough-off either. I used to walk about 2 miles a day across campus. I lift weights, kayak, ride horses, cross-country ski, hike, hunt and fish – if I can’t be outdoors with my horses and dogs I see no point in living. Physical fitness is a priority and losing a leg is a small obstacle as far as I’m concerned. After all, if Sarah Reinertsen can do the Ironman, I can do what I want to do, right? Sorry, but that’s wrong. Who determines the limits on my physical ability? Not me, not my physicians, not my prosthetist, but my insurance company.
The administrators of my insurance contract considers the components necessary to build my permanent prosthesis and meet my activity level to be “Deluxe” and therefore, not covered. Wrap your head around that word. I see luxury items as yachts, maybe a Mercedes, a Rolex watch. A “deluxe” prosthesis? Is it gold-plated, fur-lined and diamond encrusted? Hardly! I don’t need a “deluxe” prosthesis, I just need to walk and do the things I do.
As a matter of fact, the prosthetics industry has no basic, standard or deluxe legs on the shelf. Each prosthesis is matched to the wearer’s activity level. A knee designed for high activity and sports will not be suitable for an 85-year old grandmother and Grandmother’s knee won’t help the athlete ski down the mountain. When did limbs cross the boundary of being an essential part of our body to luxury options?
The dirty secret is that there is no prosthetic parity. While the Veteran’s Administration, Medicare and Medicaid cover microprocessor components, many private insurance companies do not. It’s up to the individual insurance companies or plan administrators to determine coverage, and thus your quality of life. Some put a cap on the price, usually a ridiculous amount that wouldn’t pay for a big toe. Others give you “one limb per life” which leaves me asking, “How many lives do I get?” Others consider a prosthetic limb to be “cosmetic.” If that were the case, I should be able to get a face-lift, breast implants and a leg from my local plastic surgeon! Ten states have now passed prosthetic parity laws which require insurance companies to cover prosthetics the in the same manner as they cover other medical procedures and devices. Missouri is in the process and Kansas currently has no existing legislation. A Federal Prosthetic Parity bill was introduced on March 13, 2008 (House Resolution 5615).
I find it incredibly ironic that I work for the State of Kansas at the premiere medical and research facility, yet I am not afforded the same prosthetic coverage as a patient with Kansas Medicaid or a Kansas veteran. So, I decided to fight. After 4 months of appeals and documentation that the prosthesis is medically necessary and that my functional level meets and exceeds those needed to operate the prosthesis, I’ve been told that I’ve exhausted my appeals and that “We’re sorry there wasn’t a more favorable outcome for you.” Well, I’m sorry too. I’m probably sorrier than they are. As much as I hate the public eye, I’ve been complacent too long.
This is the beginning of my quest for prosthetic parity.
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