Insurance Coverage For Prosthetics or Orthotics

Never far from any discussion of advanced prosthetics and orthotics is the companion topic of cost and reimbursement. Like most new products providing new and improved capabilities, breakthrough prosthetic components like the C-Leg, Proprio Foot and Advanced Arm typically come with a hefty price tag and thus may be financially viable for only a small percentage of individuals with congenital or acquired limb loss. Obtaining insurance coverage for advanced prosthetic systems is usually a long and arduous process, which often doesn’t bear fruit.

The difficulty of obtaining adequate third-party reimbursement for a prosthesis of any type has been a growing challenge in our business for years. Whereas the federal government has mandated full prosthetic coverage for military personnel with limb casualties sustained in war, Medicare maintains significant coverage limitations, and many private insurance companies offer far less, in some worst cases limiting amputees to reimbursement for one prosthetic limb in a lifetime…or providing no coverage at all.

In early 2006, an Amputee Coalition of America poll of 660 users on the ACA web site – – revealed that of the 423 respondents who reporting having private insurance:

  • 62 percent reported their prosthetic coverage had remained the same in the past three years;
  • 31 percent said it had been reduced, and
  • 7 percent stated it had been eliminated altogether.

ACA has since championed an advocacy program to promote passage of “prosthetic parity” legislation that would ensure an appropriate minimum level of prosthetic care for Americans with limb loss. Subsequently, the Orthotic & Prosthetic Alliance, a coalition of national organizations representing the O&P profession, began advocating “for fair and equitable coverage and reimbursement policies so that patients have access to technology and can continue to receive high quality orthotic and prosthetic services.”

By the end of 2006, six states – Colorado, New Hampshire, Maine, Rhode Island, Massachusetts and California – had passed parity bills, most of which mandate that private insurers in the state provide coverage for prosthetic devices at least equal to federal laws and regulations for the aged and disabled.

Another 11 states, possibly more, reportedly will consider similar legislation. Nevertheless, the push for parity is not without controversy. Among qualified prosthetic practitioners is a serious concern that less-than-specific language in different state bills with regard to provider credentials may lead insurers to direct policyholders to underqualified providers. At the end of 2006, only 10 states required prosthetists to be licensed. In concept, however, prosthetic parity laws are a step in the right direction. As supporters of such legislation in various states continue advocating for services to be provided by appropriately credentialed prosthetists, we make progress toward an acceptable level of care for all individuals with limb loss.

If you have any questions about insurance coverage for prosthetics or orthotics, please contact LeTourneau Prosthetics in Beaumont, Nederland or Jasper, Texas.

We look forward to helping you with any of your orthotic or prosthetic needs. Please call us today for your free consultation. We will be glad to answer any questions you may have.