After some active support from the ACA, concerned intervention from Limbs for Life, and more than a little applied pressure, a Kansas City amputee is now looking forward to a fully-funded prosthetic limb. Not only is turnabout fair play, it can be extremely welcome news.
Early last summer, Larry Gates had the rug pulled out from under him in his attempt to get back on his feet. His claim for reimbursement of a below knee prosthesis didn't have a leg to stand on. His HMO simply denied it. Sorry. Prostheses aren't covered under that particular plan.
However, after some active support from the ACA, concerned intervention from Limbs for Life, and more than a little applied pressure, this Kansas City amputee is now looking forward to a fully-funded prosthetic limb. Not only is turnabout fair play, it can be extremely welcome news.
To recap Larry Gates is a 49-year-old claims adjuster employed for the past 15 years by the U.S. Social Security Administration, the government agency that distributes funds to people with disabilities. Last May, he became a below knee amputee after an osteosarcoma was discovered in the calf of his right leg. Surgery excised the cancerous tumor and left him in need of a prosthesis.
Fine Print Vetos Leg
Unhappily, a check of the fine print in his Kaiser Permanente HMO health care plan revealed a specific exclusion of prosthetic care. Ironically, the policy would reimburse for an internal prosthesis an artificial hip or knee but not for a limb that would allow him to return to work and stay off the federally-funded disability rolls. His choices appeared to be using crutches or a wheelchair, or financing a prosthesis by himself.
"It would be great if I didn't have to pay for the whole thing out of pocket," Larry noted in an inMotion article that appeared in our June issue.
Responding to Larry's plight, ACA Board members put the Kansas City, Missouri, resident in touch with Oklahoma City's Limbs for Life prosthetic program to see if he could receive partial reimbursement.
Meanwhile, Larry continued with his three-times-weekly physical therapy and biweekly chemotherapy treatments. Although he could gradually put more weight on the recovering leg, he still used crutches while wearing his immediate postoperative prosthesis.
By mid-summer, Limbs for Life contacted Larry and his wife Renae with the news that a new foot from Campbell·Childs would be on its way to Larry's prosthetist. It didn't arrive. After weeks of waiting, Larry was told that the Oklahoma City organization would send another foot.
"And that's when UPS went out on strike," Renae laughed. "It seems that foot was somewhere in limbo until the drivers went back to work."
The tale gets better...
Shortly after the UPS walkout was resolved and packages were again on the move, Larry's prosthetist phoned to say she had received the foot.
"And then a Kaiser representative called the very same day to tell me the company would cover both the temporary and permanent legs," Larry added.
The case manager told him that the insurer had an agreement with the federal government regarding prosthetic coverage, even though it wasn't in writing. The news was a surprise, especially since his request had been flatly denied twice by two earlier case managers who had reviewed his file in previous months.
"It was just wonderful when I found out that Kaiser was going to pay for it!" he noted. "My new prosthesis will have all the latest technology; I'm really anxious to get it."
While the present looks rosy, Larry's insurer hasn't yet said whether it will cover the cost of future prosthetic repairs or replacements. But that's tomorrow's problem.
Back to work
On September 8th, Larry Gates headed back to work as a checks claims recovery examiner, tracking down lost or stolen Social Security payments. He is still using crutches while navigating on the temporary prosthesis. And he continues both the physical therapy regimen and chemo treatments. An adaptive device lets him control his car using only his left leg.
"Larry's 6-foot-4", and it's been terribly exhausting for him to use the crutches all these months," Renae said. "He'll continue the chemo until late fall. Although it caused hair loss, he's looking and feeling well. I'm glad we're finally beyond all the red tape and we're very grateful for all of the help from the ACA and Limbs for Life.
"Everything's looking great!" she added.
