College student fights insurance denial to get a prosthetic foot before graduation
Gabrielle Guerrero was 15 when doctors told her that her life would never be the same.
“They were like, ‘You’re young and energized, but you’ll never be able to walk again without assistance,’” said Guerrero, of Burleson, Texas, a suburb of Fort Worth.
She had been riding in an off-road vehicle with her siblings when it hydroplaned and flipped. Guerrero’s left foot caught in the door. After more than two weeks in the hospital and two surgeries, it ultimately had to be partially amputated. Guerrero lost all of her toes and about half of the front of her foot.
To get around comfortably, Guerrero, now 21, wears a custom prosthesis.
“When I walk barefoot on hard floors, it’s very, very painful, I can feel the callous, the pressure on it,” she said. “So when I wear that prosthetic, it takes that pressure off.”
But six years later, the prosthesis had worn down. Two of the fake toenails had fallen off and a tear down the back made it difficult to stay in place. “It was literally disintegrating,” she said.
That first prosthesis had been fully covered by Guerrero’s insurance provider, Aetna. However, Aetna denied coverage for the new prosthesis, writing in a September letter that the request was “improperly coded” and a prosthesis “for appearance, comfort, or convenience is not considered medically necessary.”
“I was honestly just in tears because of the anger,” she said of the denial. “I don’t understand how comfort isn’t medically necessary.”
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She had a deadline in mind: her December college graduation, where she hoped to walk across the stage wearing the new prosthesis.
NBC News reached out to Aetna for comment eight days before Guerrero’s graduation. A spokesperson said the company would look into the details of her case.
Several days later, Guerrero received a second denial.
With the date rapidly approaching and no resolution, her mother made the decision to put the $7,500 cost for the prosthetic on a credit card. The device was ready to go, but Guerrero couldn’t take it home until it was paid for.
“It’s like a slap in the face,” Guerrero said. “I know my mom pays thousands of dollars and thousands more in deductibles.”
The day after her graduation, Aetna provided additional information to NBC News about the two denials. A spokesperson said that during a follow-up peer-to-peer conversation that Aetna had with the prosthetist who prescribed the device, the prosthetist “was unable to answer fundamental questions about the submitted claim.” The spokesperson also said the prosthesis requested didn’t meet criteria “to improve and restore function and mobility” and may slip off and cause a trip or fall.
Guerrero’s prosthetist did not respond to a request for comment.
Several days later, Aetna reversed its decision, saying in a statement to NBC News: “Now that we have more critical information than what the original prosthetist was able to provide, the insuring plan sponsor for Ms. Guerrero has agreed to grant coverage of the prosthetic.”
Not a matter of if but when
Insurance denials for prosthetic devices are not uncommon.
“The amount of denials that our community faces is prolific, and it’s not a matter of if you’ll be denied, but when,” said Nicole Ver Kuilen, the director of impact campaigns for the Amputee Coalition and the national lead for the So Every BODY Can Move campaign. Ver Kuilen lost a limb due to bone cancer as a child and said she has personally dealt with insurance denials.
Insurance coverage for prostheses varies from state to state and depends on the type of plan, Ver Kuilin said. At least 25 states have passed legislation requiring state-regulated insurance plans to offer the same prosthetic coverage as Medicare, which generally covers devices that replace a body part or function and requires a 20% copay.
Gerald Stark, president of the American Academy of Orthotists and Prosthetists, said almost all of his patients have received a denial of some sort.
“They all get a refusal of care. And so you just learn to write letters,” said Stark, adding that he’s seen denials claim that the prescribed prosthesis was not medically necessary, was not an established form of care or was not from an in-network provider.
“I think what they’re trying to do is get the patient to say, ‘OK, well, I’m tired of advocating. I’m just done with that,’” he said.
Beyond insurance and financial barriers, access to a qualified prosthetist can prevent patients from receiving the devices they need, said Dr. Jerry Grimes, a foot and ankle orthopedic surgeon at Texas Tech Physicians.
“Prosthetics are sort of an art, and so many times it takes multiple visits to be successful with a prosthetic,” Grimes said. “Some of these people have to travel 100 miles to go to a prosthetist. Then, if it needs adjusting, two weeks later, they’ve got to go back.”
To get her new prosthesis took six visits, Guerrero said, including four specifically focused on making sure the device properly fit.
Her mother was ultimately reimbursed for the full cost of the prosthesis after Aetna reversed its decision.
“I didn’t expect a reimbursement after my mom already pulled the $7,500, so I was just super happy, and I’m glad that we got it right at the holidays,” Guerrero said.
“Don’t give up,” she added, referring to her push to get the prosthesis covered. “Whether that’s just multiple people calling in for you and advocating for you, whether that’s reaching out to another doctor to add more professional insight. But just never give up, because eventually they’ll say yes, or I hope so.”
