How have you been able to justify microprocessor technology?

We’ve gotten a few of them through by telling the insurance companies what benefits the microprocessor has for a patient’s work style. We’ve had some factory workers, and I’ve got a lawyer who’s on a C-Leg. It helps him walk up and down steps and it helps in the courtroom—it [looks] more natural. We were able to get that through, but they would only pay half the cost.

Insurance companies don’t seem to want to put them on older people, even though the stability factor’s there. If you get a younger person and you start fighting, you can sometimes get it processed.

I think the new movement by the Army and the government is going to help us. The VA now accepts the fact that this is what we need to do. Private insurance companies still think it’s experimental and do not want to authorize it.

Why is it that the manufacturers are not going to the insurance companies and holding demonstrations and proving to them that it’s not experimental?
Bob Weygandt, CP, FAAOP
Wrymark Inc./dba Resource O&P
St. Louis, Mo.

There have been two instances where we’ve had new mothers [as patients], and I’ve [written] a letter stating that a mother needs to hold her child, and a microprocessor is very safe in that respect, and they’ve accepted that.

A lot of times, we know when it’s going to be futile to go through the process, and that’s when we make the patient become an advocate. We have gotten a couple through [that way]. The [patients] will kick and scream until [the insurance company says] “Okay, we’ll pay for it.”

Normal daily activities [work as a justification] more for people in their fifties and sixties [who] we’d put a microprocessor on for safety issues.

We focus on [patients’] jobs and say why they need [the microprocessor]. One guy was a farmer—he’s walking on uneven terrain and he’s got to check his crops. And we had a train engineer who’s got to walk over the train tracks and get up into his train.
Michael Clapp, CPO
SCOPe Orthotics & Prosthetics Inc.
Orange, Calif.

So far, I’m 100 percent, but it’s because I’m choosing the people who I know are going to get them. The optimum patient is one who’s using another knee, and it’s limiting his daily activity because of falls, or other reasons related to his specific job or activity. We have instances of x number of falls per week or per month, and putting on the C-Leg or the Rheo Knee would [give] better stumble control. That’s our technique, and we’re successful because we don’t put them on everybody.

I have an actor who has both legs off, one below and one above the knee, and we were able to validate that when he’s on the set he cannot be safe and walk around without problems. [A] second patient is having difficulty, as he’s getting older, to catch himself [and keep from falling]. So these are optimum patients.

We’ve had Medicare pay for them, we’ve had Blue Cross pay for them, we’ve had Motion Picture Hospital pay for them. We were able to get them through Blue Cross on first or second appeal.
Keith Vinnecour, CPO
Beverly Hills Prosthetics
 Orthotics Inc.
Los Angeles, Calif.

We get some with the VA or workers’ compensation [claims]. With workers’ comp, the accident happened at the job, so they aren’t looking at it as strictly as a private insurance company would. They don’t want a lawsuit if they don’t provide something.

We tell them that the patient will benefit because the patient is an everyday ambulator in the community, and [the microprocessor] will give them the ability to walk more efficiently, be a little safer on uneven terrain and [walk up] steps and ramps with a normal step-over-step. That’s generally the main argument.
Lisa Hewitt, CP
Harry J. Lawall & Son Inc.
Philadelphia, Pa.

We have a patient who’s been accepted, but we’re still fighting because [the insurance company] wants another thing and then another before they’ll pay. [They ask for additional documentation] sometimes up to six or seven times.

We have gone so far as to put a patient into a [microprocessor] system on a trial basis, and document that the patient is more stable, more comfortable, capable of performing more activities of daily living and is safer in the workplace [than on the previous prosthesis], and still be denied coverage. We had a very black-and-white difference in the [patient’s] capabilities, and the insurance company still refused. That patient had to go back to the original prosthesis.

I had a patient come in who had had cancer treatment, and he said getting cancer treatment was tough, but nowhere near as bad as dealing with insurance companies.
John Tyo, BOCP, CP, President
CNY Prosthetic Center
Syracuse, N.Y.