A lower extremity prosthesis (leg) can range in cost from $5,000.00 to $50,000. An upper extremity device (arm) can range from $3,000.00 to $30,000.
Why pay for a Cadillac, when a Chevy will do?
How does the saying go?
If I had a nickel... So it goes with this phrase; repeated by rehabilitation claims reviewers and insurance payers, demonstrating that there is a growing national trend towards evaluating the medical necessity of a claim simply for its overall cost.
Generally, an understanding exists between payer and beneficiary, that any catastrophic, illness or event involves an issue of financial responsibility. However, the expectation persists that insurance will provide for the purchased services.
Why the difference and why not just give everyone the less expensive variation?
Cost does not define medical appropriateness.
An amputee's residuum, age, daily activities, profession and certain health factors determine the specific materials and technologies used for each custom manufactured device.
A prosthetic is device is made up of moving parts.
Parts wear down; interfaces need replacement.
Humans grow, gain or lose weight, change in shape.
All of these factors contribute to need and cost.
A prosthetic device can be body powered or computerized, made of aluminum, stainless steel, titanium, plastics or carbon composites. Even the most expensive prosthetic limbs are built to withstand only 3 to 5 years of wear and tear, meaning they will need to be replaced over the course of a lifetime - and they're not a one-time cost.
The California Health Benefits Review Program determined the cost of California State parity would be approximately $.25 per insured member.
Additionally, a recent survey found that every $1 dollar spent on rehabilitation saves the economy $11 dollars in various welfare and disability benefits.
On the other hand, a person who does not receive a prosthetic within 2 years of amputation has a greater likelihood of social welfare, increased health concerns including obesity related diseases and conditions and is more likely to suffer depression.
The US amputee population is approximately 1.9 million persons and growing, however science and medicine provide the technology to restoring a person's dignity, self-reliance, productivity and ability to contribute to society.
In consideration, the benefits to the person and to the community far outweigh the cost of provision.
It is state or federal legislation requiring insurance companies to pay for prosthetic devices on par with federal programs, payment rules and regulations. Federal Program could be Medicare, Medicaid, or programs such as the Federal Employee insurance held by Congress and other government employees.
These programs provide reimbursement without capitation or exclusions for medically necessary services such as prosthetic devices.
For further information see our article What is Prosthetic Parity.