Today I had an interesting experience.  I had an insurance company medical director decide that a myoelectric prosthesis was not medically necessary.  Mind you, the insured person had no specific limitation in his plan for myoelectric or microprocessor prostheses.  The plan simply stated that coverage for prosthetics was based on medical necessity.  Today, this myoelectric prosthesis was not considered a medical necessity.  The insurance representative went even a step further by saying that the myoelectric design is a 'luxury'.  Funny thing is... this same insurance company authorized a myoelectric prosthesis for another client just a few months ago. 

The writing of many insurance plan provisions beg for subjective interpretation.  Before an insurance representative denies coverage for something based on subjective writing (denied for medical necessity, etc..), I would encourage the representative to:

• Look at the amputee's background.  If an amputee has been using a myoelectric prosthesis for 10 years, there's probably a reason why.  Also, a change in condition could necessitate moving from a body-powered design to a design with external control.
• Read the physician documentation.  Insurance medical directors should contact the prescribing physician for more information.  A major determination many times cannot be ethically made without contacting another medical professional familiar with the patient's needs.
• Consider alternatives.  If denying a prosthetic design, I would hope that alternatives are given.  If a body-powered prosthesis is contraindicated for an amputee, there may be no good alternative to a myoelectric.
• Keep long term costs in mind.  If the need is legitimate, many patients will fight a denial to the end.  When you consider the long term costs of litigation, authorizing prescribed and legitimate prosthetic care doesn't sound so expensive.  Also, if an amputee doesn't get the care he or she needs, that person may become a lot less active.  Decreased activity like that can cause physical and mental health decline, which could translate into more cost to the insurance company in the long run.
• See it from the amputee's perspective.  No prosthetic limb is going to be as good as the real thing.  If we had our way about it, most of us wouldn't even have to deal with this issue at all.  If I were an insurance representative making this crucial determination, I would ask myself, "what if this was my mother, or my daughter."  Remember, insurance company... there is a person behind that member identification number.