A leg to stand on

Caveat: If you’re here because you Googled the term “erectile dysfunction,” you’re in the wrong place.

Caveat #2: Every statement in here is my opinion.  I have not done any research on statistics to support my statements, but if you have any numbers to either support or refute what I’m saying, I am more than happy to hear them.  Make sure you’re polite, or I’ll delete your comment without warning.  I won’t tolerate nonsense.

My son is an amputee.  He’s 18 years old.  His left leg was amputated 8 years ago because he had cancer.  Actually, he’s had cancer three times, and his leg was amputated the second time he had cancer.  The third time he had cancer, they removed the offending lymph node, radiated him and put him on drugs for 3.5 years.  These drugs hopefully did the trick — he’s now cancer-free, but he still doesn’t have his left leg back.

I just spent days drafting a letter to our insurance company explaining why their denial of coverage for a microprocessor knee was unreasonable.

Insurance companies have a strong history of providing prosthetics that return an amputee to what they call “minimal basic function.”  There is a large chasm between what an insurance company considers to be minimally basic and what an amputee considers to be minimally basic.

What would you consider to be basic and minimal for an 18-year-old?  I think it’s pretty basic to be able to walk across the floor with the expectation that you won’t fall down, and it’s pretty minimal to expect to be able to climb stairs in a normal fashion.  My son doesn’t enjoy either of these basic, minimal functions.

Would running away from danger be considered basic or minimal?  He can’t do that, either.

How about remaining upright should someone accidentally bump into you?  That’s pretty basic … fairly minimal, I would say.

Let’s say you’re standing on an L-train platform in Chicago.  It’s rush hour.  The train is coming and someone’s in a hurry to catch that train because they’re late for work.  Let’s just say you have one good leg to stand on and you’re bumped while you’re standing there with a backpack on your back.  Let’s just say it would be pretty darn basic to be able to catch yourself before you fall on the tracks.

The other requirement insurance companies like to wave around is “Medically Necessary.”  This term is open to so much interpretation, and I imagine it’s pretty easy to categorize a lot of procedures, drugs and durable medical equipment as “not medically necessary,” but when an insurance company categorizes erectile dysfunction drugs to be medically necessary but denies coverage for microprocessor knees, you have to wonder who is setting their priorities.  I do not minimize a woman’s devastation when a mastectomy is required, but I think any woman would agree that you can do pretty much anything without breasts, yet reconstructive surgery is covered by most insurance plans.

Why isn’t the new technology that has become available for amputees not considered as important as ED drugs,  breast reconstruction and even birth control?

With a microprocessor knee, an amputee can walk with a normal gait at a normal pace, and that removes strain on their hips, back and the joints in their other leg. They can move more freely and that will encourage them to be more active which will, in turn, allow them to build their stamina and strength.  All of these things work to prevent severe orthopedic problems, cardiac disease, Type II diabetes, depression, and — by George — I bet it helps to prevent erectile dysfunction or breast cancer, too!  Win-win!

I know I’m pretty biased about this issue, but I like to think that I’m looking at this in a balanced fashion.  I would want these things for any amputee even if he or she wasn’t my child.  I want these things for anyone who has gone through the trauma of sacrificing a limb to save their life or the lives of others.  That’s an enormous sacrifice, and when a company with a $9 billion revenue stream says they’re not willing to sacrifice a small percentage of their revenue to return these individuals to a level of function they’d surely demand for themselves, then I call foul.

We are still waiting to hear the decision on our appeal.  I might be jumping the gun here with my rant.  I just find it so frustrating that we have to play this game.

UPDATE 6 YEARS LATER:

The insurance company agreed with me, and my son has enjoyed the functionality of a Genium knee from the time he started college until now. It has made all the difference in his mobility. He’s a happy, healthy, self-supporting adult now. What more can a parent ask for?!

I’m not sure why I didn’t post the entry above when I wrote it, but I didn’t. Having it here will hopefully help someone else who is getting ready to write an appeal to their insurance company.