Navigating Upper Extremity Amputation

A few months after my amputation, my surgeon referred me to a local prosthetist. After discussing options and what my plan would cover, we decided a myoelectric prosthetic would be the best fit for my needs at work and home. We started the preauthorization process, met with reps, and worked on molds for the final socket.

Less than 4 months after my amputation, I had a prosthetic. For the first few months, I could only wear it for short stretches, both due to the weight of the prosthetic and because my limb was still maturing. During that time, I wore and used it as much as I could—at work, for cooking and doing laundry, while exercising, etc.—and I began to rely on it for tasks that required additional grip strength and dexterity.

Starting the Process

Late last summer, I began to have issues with the fit of my socket. This is normal since the size and shape of an amputated limb change rapidly over the first few years. We started adding padding into the socket to fill the extra volume, but eventually, I would get severe blisters on my arm after just a few hours of use.

My prosthetist decided it was time for a new socket, so we started the process of recasting and creating check sockets to get the right fit. The second time around was a much bumpier process. We went through probably 8 different versions. (One was too big; then too small; then the mold broke.)

When we were finally getting close to the correct fit, my prosthetic hand broke and needed to be shipped out for repairs, setting us back another 6 weeks. In the background, we were also working on insurance preauthorization, since we were hoping for a billing and service date before the end of the year.

Submitting for Pre-Authorization

We submitted for a 12/18 service date … and waited … and waited. Both the prosthetist’s office and I could see that the pre-auth had been denied, but no letter, no rationale, and no instructions for appealing the denial. The provider called multiple times requesting the letter, and then I called:

“Hey, we need the denial letter, so we can submit an appeal.”

“We sent one out. Your provider didn’t receive it?”

“No, and it’s not in my patient portal. Please send it to both of us.”

“Hmmm… let me check on that.”

…

“So your denial letter hasn’t been generated yet.”

“Okay, your website says the letter will be posted within 72 hours. It’s been over a month, and you just told me you had already sent it to the provider, so when can I expect it?”

“Within the next 48 hours.”

48 hours and 0 letters later, I decided to bring my company’s HR department into the conversation.

First Denial

My HR rep reached out to UMR and was able to get some answers about why the pre-auth was denied and instructions for submitting an appeal. Basically, the denial boiled down to:

1. Your plan doesn’t cover this type of prosthetic. (Okay, but you already covered the prosthetic. This is just a new socket.)
2. We’re not convinced you need this. (I disagree and so do my doctors.)

We started gathering everything for a provider appeal, including clinical notes from my surgeon and prosthetist and submitted the appeal.

I followed up with HR to let them know it had been submitted and to see if they could keep it moving forward.

Confusion and Misinformation

Later that day, my HR rep emails me, saying that UMR told her that providers can’t submit appeals only provider inquiries, and those have a 90-day processing time, directly contradicting their earlier appeal directions.

When I get home from work that day, I called UMR, laying out everything that had already happened, from the missing denial letter to the provider appeal. The rep said that they had received the appeal and we had done everything correctly, but I needed to submit one more form before they could start processing it, which was a 15-30 day timeframe.

Back at work the next day, I reached out to HR with an update. My HR rep said that their UMR contact “vehemently disagreed” with everything I had been told the night before, leaving me to scour UMRs website to verify the appeal process. Everything I found aligned with my conversation from the previous night.

My company’s UMR contact thought we were inquiring about a different type of appeal and didn’t check my account or find the pre-auth request before “vehemently disagreeing.”

Second Denial

That hurdle behind us, we were back to the waiting game. 2 weeks later, I received pre-auth denial number 2, in which a board-certified doctor explained to me why I don’t need my current prosthetic.

Less than 3 days later, my provider and I each submitted our own second level appeals with even more clinical notes and a patient impact statement detailing how I use my prosthetic and why I need it.

I still have not received a response and have now been waiting on a new socket for 7 months. My prosthetist assures me that this is “normal” and that the insurance company wants us to give up before we get the approval. I refuse to let that happen.

While I know I am blessed to have access to health insurance at all, insurance companies relying on lack of transparency and misinformation to prevent people from receiving proper care is not okay and should not be normalized.

If you’re going through something similar, I want to encourage you to keep calling; to enlist as many advocates as you can on your behalf; and to remind them that you’re a real person, not just a case number. Hopefully, I’ll have a positive update soon, and know that I’m cheering you on.