Successful Outcome on HMO Denial of Prosthesis

I have been working with a practitioner in the Northeast for many months in an effort to force a local HMO to authorize the prosthesis that was prescribed by his patient's physician. This unilateral transfemoral amputee seems to be an excellent candidate for the prescribed C-Leg, and has a well-documented history of falling down due to intermittent collapse of his hydraulic stance and swing control knee. He is a manager of a small business and works long hours on his feet, often in areas where the floors are uneven or slippery.

The HMO has never contested the doctor's opinion that the patient would be far better off with the prescribed limb. But, they have used every argument they could muster to argue that although his group policy states that it "covers artificial limbs", they are not obligated to authorize anything that would make it safer for him to function at work. Initially, they cited a policy exclusion for "services required to enhance employment". On appeal, we refuted that denial by demonstrating that the exclusion was intended to refer to mandatory physical examinations and similar job requirements, not the use of an artificial leg.

The initial reviewer, who worked for the same HMO, then denied the claim on the basis that a safer prosthesis was "not medically necessary for treatment of a physical condition". We dutifully worked through all the levels of internal appeal over the ensuing months, refuting various proposed reasons to deny the prescribed care, one-by-one. At each level, different internal HMO staff upheld the denial, although the reasons shifted from reviewer to reviewer. Eventually all appeals had been exhausted, and this HMO did not permit review by impartial outside experts.

The patient then sued the HMO, and with the help of a local lawyer, was able to obtain external review by a Board-Certified specialist in Physical Medicine and Rehabilitation. The independent PM&R physician agreed fully with the prescribing physician that the prosthesis was appropriate, medically necessary, and must be covered by the HMO.

I have assisted in a number of similar appeals in the past couple of years. Sometimes we have been successful in persuading internal staff to overturn denials; sometimes not. But thus far, in every case where we were able to obtain a review by an independent expert, the prescription by the patient's personal physician has been upheld and the HMO denials overturned.

Fortunately, in most states the HMO must ultimately allow an independent review, and there is no need for litigation. Personally, I would like to see a Federal Patient Bill of Rights that would guarantee consistent oversight to all HMO patients. That would eliminate the costs of litigation, insure more unbiased coverage decisions, and eliminate the need for the Supreme Court case in the previous article.

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