Trans-femoral Amputation: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that The patient requested authorization and coverage for a Ossur Rheo microprocessor knee and Ottoback Maverick Comfort AT prosthetic foot.Current literature regarding the benefits of microprocessor-aided prosthetic knees relative to prosthetic knees without microprocessor-aided control is largely mixed and based on small patient numbers with low-quality data. A study indicated that there is a lack of high quality evidence showing improvement with microprocessor-aided prosthetic knee devices on the risk of falls and gait parameters over prosthetic knee devices without computer control. Further, the studies promoting motor-processor controlled knees are of low quality.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for endoskeletal knee/shin system with microprocessor control. There is a growing body of medical literature to support the use of microprocessor-controlled prosthetic knees for certain patient groups. Researchers note that the benefits of microprocessor-controlled prosthetic knees (MPKs) have been well established in community ambulators with a transfemoral amputation (TFA). The authors noted that a literature review suggests that limited community ambulators may also benefit from using an MPK in safety, performance-based function and mobility, and perceived function and satisfaction.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has a history of multiple chronic medical conditions, including arthropathy, for which he underwent a total left knee replacement in the past. This was complicated by an infection, and he ultimately underwent a left transfemoral amputation on 11/1/11. The patient underwent rehabilitation, including prosthetic ambulation training. He received a `preparatory` endoskeletal prosthesis in or around 2011 with an Ossur Symbionic (microprocessor-aided) knee, but he reportedly gained weight and could no longer use this prosthesis. Case management notes indicate that he received a replacement prosthesis in 2013 due to a weight gain of approximately 80 lbs. On 9/17/18, his provider noted that he is a current smoker of 11-20 cigarettes per day.

Physician 1: The patient is a 24-year-old female who is status post right trans-femoral amputation following a motor vehicle accident in 2001. Her physician states the patient has used a wheelchair since the accident due to the fact that her limb is too short for a prosthesis. Her physician also indicates the patient underwent revision of the residual limb in October 2004 and has recovered well enough to allow her to use a prosthesis. The patient’s physician has recommended the patient receive an Otto-Bock C-leg prosthesis.There are no case-controlled, randomized studies demonstrating the superiority or improved functional outcomes of the Otto-Bock C-leg prosthesis compared to standard prosthetics.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for trans-femoral amputation was denied, the published record says the denial is worth fighting.