Services

Insurance Reimbursement

CONTENTS:

II. Steps To Take After Submitting Pre-authorization

III. Justification of a Myoelectric Powered Prosthesis - Summary of Benefits

IV. Impact On The Actual Tasks The Wearer Performs In His/Her Daily Life
    A. Below-Elbow Amputees
    B. Above-Elbow Amputees / ServoPro Option
    C. Shoulder Disarticulation, Forequarter, and Brachial Plexus-Injured Amputees/ ServoPro

V. Comparisons With Alternative Components
    A. Otto Bock Below-Elbow Prosthesis
    B. Boston Elbow
    C. Hosmer Elbow
    D. Other features of the Utah Arm

Insurance funding of a Utah Artificial Arm prosthesis can, and has been, obtained in literally hundreds of cases. Nearly all the Utah Arm prostheses fitted have received third party funding. However, insurance providers will want to carefully evaluate this benefit, and will expect a well-documented proposal. Initial and long-term cost of myoelectric prostheses are higher than traditional body-powered arms. Proper strategy is important in a pre- authorization request.

Many insurance company personnel are not familiar with newer technology. Because of this, part of applying for pre-authorization is largely educating the insurer about the benefits of an electric prostheses. To avoid delays and increase the likelihood of a favorable reply, prepare all materials which justify the claim beforehand. Try to anticipate possible questions. Once submitted, follow up to make sure the request does not get "lost in the system."

The following information is provided to help you prepare a well documented request. Please call Motion Control with questions or for more specific assistance.

We hope this information will assist you in building a strong case for an appropriate Utah Arm or ProControl candidate. Ask us for the Model Letters packet, for additional help with composing an effective letter of justification. If we can supply any further information, please feel free to call, e-mail, or write us at the address at the bottom of this page.

References

1. Kritter, Alfred E.: Current Concepts Review: Myoelectric Prostheses. The Journal of Bone & Joint Surgery, Vol. 67-A, No. 4: 654-657, 1985.
2. Millstein, G., Heger, H., and Hunter, G.A.: Prosthetic use in upper limb amputees: a comparison of the body powered and electrically powered prostheses. Prosthetic & Orthotic International, 10: 27-34, 1986.
3. Reddy, M.P.: Nerve Entrapment Syndromes in the Upper Extremity Contralateral to Amputation. Arch Phys Med Rehabil Vol. 65, 24-26, 1984.
4. Sears, Harold H. and Shaperman, Julie: Proportional Myoelectric Hand Control: An Evaluation. Amer. Journal Phys. Med. Rehabil., Vol. 70, No. 1, Feb. 1991.
5. Jacobsen, S.C., Knutti, D.F., Johnson R.T., and Sears, H.H.: Development of the Utah Artificial Arm. IEEE Trans. on Biomedical Engineering, Vol. BME-29, No. 4, April 1982.

I. OBTAINING INSURANCE PREAUTHORIZATION: AN OVERVIEW

B. Obtain Prescription. A prescription must be obtained from a physician for a "myoelectric elbow and hand (wrist and electric hook, if appropriate) prosthesis, Utah Artificial Arm type." Your physician should also write a letter of justification (as described in Section C below), stressing that the prosthesis is medically necessary.

C. Letter of Justification. A letter of justification must be written to explain the medically necessary rehabilitation benefits of the planned prosthetic care. The letter should be written by the prescribing physician. The prosthetist may provide additional information. We advise that the benefits of the myoelectric prosthesis be related to the patient's work and personal needs as specifically as possible. See Section IV for a summary of such benefits.

D. Prepare Estimate. A complete quotation for delivery of the prosthesis should be prepared by the fitting center. The quotation should describe the purpose of all components to be delivered. Training, follow-up, extended warranty and any other services should be estimated for the insurance company at this time.

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II. STEPS TO TAKE AFTER SUBMITTING PREAUTHORIZATION:

B. Persevere. If the claim is denied, don't give up! Remember this is only their first response, not necessarily the last. Request a written response, detailing the reasons for denial. You will then have something specific to answer.

C. Answer Objections. Inform the physician and prosthetist should you receive a denial. The physician should write a response, using the information in this paper, to negate their objections. Motion Control can also supply reprints of reference articles from medical journals documenting the benefits of myoelectric prostheses (see sidebar). For instance, if a claim for a Utah Arm is refused as "experimental," the objection can be refuted by citing experience with over 1,000 fittings since 1981.

Send an appeal to the claims manager (or the insurance companies' specified contact), with a copy of the original claim. Then call to make certain it was received. Ask about appeal procedures and the time involved. The appeal will probably be handled by a "medical reviewer" or committee. Be sure this review is conducted with all available information on hand. If the first appeal is denied, ask again for the denial in writing. Also, inquire whether another appeal is possible, to a higher level person or committee. Should you be denied again, then answer (or ask the physician to answer) all objections and resubmit. Be patient and persistent. Many claims have been authorized after two or more appeals.

D. Lodge a Complaint if necessary. If the claim has not been given fair consideration, then lodge a complaint with the state insurance commission (sometimes known as the Department of Insurance). Call their consumer information office and ask for advice about filing a complaint. In some states, you may be able to request an "insurance hearing" from the state commission, to help settle the appeal.

If all else fails and you have a legitimate claim, it may become necessary to get an attorney's advice (the possibility of legal action may be enough to convince the insurance company to pay the claim).

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III. JUSTIFICATION OF A MYOELECTRICALLY POWERED PROSTHESIS

Summary of Benefits

Hand Prehension: Motorized (powered) hand drive allows greater pinch force up to 20 lbs force (1 kg). Since a motor drives the hand, it has the benefits of both voluntary opening and closing, i.e., the wearer controls the direction and the amount of opening and closing. Body- powered hands do not allow a user good control of opening and closing force without significant effort. Myoelectric control also allows a wearer to maintain hard or light grip, without effort, e.g., when holding an object for a period of time.

For heavy work situations, the myoelectric hand is interchangeable with an electric hook terminal device. This allows the patient to have a "public" hand and a "work" hand, to allow function in almost any situation. The electric hook has the possibility of an even greater pinch force of up to 36 lbs.

Since power to the hand is controlled by the amount of the amputee's muscle contraction, the proportional control allows moderation of pinch force and the handling of fragile objects.4 Speed of opening and closing is also controllable. Sensitivity of the hand control components for the ProControl (below-elbow) and the Utah Arm (above-elbow) allow operation with just 5 microvolts of surface EMG, significantly less than other myoelectric systems. This means less effort to operate the hand.

A myoelectric prosthesis usually permits a greater work envelope for the wearer by eliminating the control cables. Since cables need not be pulled across the back, the hand may be opened and closed above the head, at floor level and even behind the back. These are very important comfort and functional benefits over body-powered arms.

Flexion/Extension of the Elbow: Above-elbow, shoulder disarticulation and forequarter amputees can flex and extend the elbow of the Utah Artificial Arm throughout a range of 15 to 150 degrees. Motorized drive means that elbow motion is achievable without fatiguing muscle effort or movement of other body joints.

Comfort is also increased when cables are eliminated. The pull of a body-powered arm's control cable creates axillary forces in the contralateral arm. It can also cause skin irritation and nerve damage.3 Myoelectric candidates with sufficient residual limb length are often fitted with self-suspending (suction) sockets. Amputees consider these sockets to be more comfortable because they eliminate or at least reduce harness loads. It must be emphasized that the comfort of the socket has a direct impact on function. If the prosthesis is rejected, or worn infrequently, because of discomfort, then it is non-functional.

The Utah Artificial Arm incorporates a feature known as freeswing. The elbow swings freely whenever the wearer relaxes the control muscles. Perhaps more importantly, freeswing is used to extend the elbow without effort. Also, because reaction forces at the shoulder and socket are lessened, the prosthesis is easier to wear while walking.

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IV. IMPACT ON TASKS THE WEARER PERFORMS IN DAILY LIFE

1. Increased functionality. The letter for pre-authorization should mention specific duties which the amputee may be expected to perform that could be enhanced by a myoelectric prosthesis. Two-handed activities such as handling papers, holding a telephone while dialing, and carrying papers or briefcases in a normal fashion, are all a common office and school tasks. In the wearer's workplace tools may be used which require two hands.

If the patient is a candidate for electric wrist rotation, specific situations may exist where using the sound hand to passively rotate the wrist would be awkward or impossible. For bilateral amputees, or unilateral amputees whose sound hand is not fully functional, or for those in danger of damaging the remaining arm, a strong case can be made for providing every available prosthetic function.
2. Broader range of occupations. The range of occupations may also be broadened for an amputee who chooses a myoelectric prosthesis. For instance, the move from blue collar to white collar occupations may be significantly enhanced by wearing a myoelectric hand, rather than a body-powered hook.
3. Increased work envelope. Usually the comfort of a myoelectric prosthesis allows a longer wearing period per day. Since there are no restrictions from a body-powered cable, the work envelope may be increased, permitting specific tasks to be performed.
4. Cosmetic benefits. The cosmetic benefits of a myoelectric prosthesis should not be described as merely a "nicer-looking" alternative. The more natural appearance lessens the psychological trauma and aids the process of adjustment. These are medically necessary benefits, not merely cosmetic frills. It must be remembered that often the attitudes of the amputee's family greatly affect the adjustment process. The family may be more supportive of a natural-looking hand than of a less cosmetic prosthesis.

V. COMPARISONS WITH ALTERNATIVE COMPONENTS

REVIEW VIDEO TAPES for Prosthetists

V1. "Utah Arm - Operations & Adjustments" - videotape. A review tape for prosthetists, covering operations, adjustments, assembly, and disassembly. Approx. 70 min.

V2. "Utah Artificial Arm - Casting and Fabrication" - videotape. Review procedures taught by Tom Andrew, C.P., for casting & fitting a transhumeral (above elbow) amputee, through the temporary socket stage.

V3. "ProControl System" - videotape. This tape reviews the adjustments, fabrication, patient training, EMG testing, and troubleshooting for the Utah ProControl System. Approx. 90 min.

V4. "Training the Client with an Electric Arm Prosthesis" - videotape. A short video course demonstrating prosthesis use training with 6 clients, including amputations from wrist disarticulation to forequarter levels. 210 min. 2 tape set.

Motion Control, Inc., 2401 South 1070 West, Suite B, Salt Lake City, Utah, 84119-1555, USA Contact us Toll-free: 1.888.MYO.ARMS, Phone: 1.801.978.2622, FAX: 1.801.978.0848, E-mail