Artificial limbs using computers and aerospace materials are changing lives by making the impossible possible for thousands of amputees nationwide.

Prosthetic technology has come so far so fast that bionic legs, arms and hands allow many who have lost limbs to disease or injury to walk, run, climb and grasp often as well as someone with natural limbs.

But for many, the advancing technology comes with a lofty price tag. And insurance coverage has not kept pace with prices, an inequity that has created several classes of patients, according to Dr. Lee Nattress, director of the Amputee Services and Technical Assistance Program in Riverside.

Then there are those who have insurance that allows serviceable prostheses but not high-tech models. Another group has inadequate coverage that provides for only basic equipment.

"There's not a lot of motivation for insurers to spend more money," said John Miguelez, chief executive officer of Advanced Arm Dynamics, a prosthetics company in Los Angeles. "Research and development isn't truly effective if it's not available to patients."

The higher the technology and cost, the closer amputees can come to achieving their maximum potential and function as those with all their limbs.

Deanna Boersma of Yucaipa needs prostheses that will allow her to keep up with her children and help her get around in her job as a registered nurse.

"I'm very active ... with two jobs and three kids, so I need to replace my legs every two or three years," said Boersma, 37, whose feet -- and later her lower legs -- had to be amputated after being scalded in bath water at age 2 ½.

Boersma uses College Park prostheses, which cost about $15,500. Because her insurer covers only 50 percent of replacement costs, she faces big expenses.

"Since I need two, I buy one and they buy one," she said. However, this time, her insurer wanted a "second opinion on the price." A different prosthetist than the one she's relied upon for the past 10 years quoted a replacement cost that was $3,000 lower.

Few peer-reviewed studies have been conducted comparing the independence, health and quality of life of amputees with and without adequate and well-fitted prostheses.

The pending legislation would require insurers to cover orthotic and prosthetic devices and services prescribed by physicians, surgeons and certified orthotist/prosthetists while eliminating a requirement that plans provide coverage "under terms and conditions that may be agreed between policy holder and insurer."

The analysis stated that orthotic and prosthetic devices can help improve physical and psychological functioning by enabling users to exercise, work and perform other activities of daily living and, thus, reduce their dependence on caregivers. But at what cost?

For $5,000 to $7,000, a patient can get a serviceable below-the-knee prosthesis that allows the user to stand and walk on level ground. By contrast, a $10,000 device will allow the person to become a "community walker," able to go up and down stairs and to traverse uneven terrain.

A prosthetic leg in the $12,000 to $15,000 price range will facilitate running and functioning at a level nearly indistinguishable from someone with two legs.

Devices priced at $15,000 or more may contain polycentric mechanical knees, swing-phase control, stance control and other advanced mechanical or hydraulic systems.

Computer-assisted devices start in the $20,000 to $30,000 range, Nattress said. These take readings in milliseconds, adjusting for degree and speed of swing.

Similarly, upper-extremity amputees can buy a nonfunctional cosmetic hand for $3,000 to $5,000 that "just fills a sleeve," Nattress said. "It allows them to get by in public without being noticed. For some, that's enough."

Cosmetically realistic myoelectric hands that open and close may cost $20,000 to $30,000 or more. These contain processors that tell how much pressure you're putting on a held object and whether it is hot or cold.

"If one device could serve everyone, then you could mass produce it and reduce costs," he said. "But these are produced in relatively small numbers and made of custom materials, with a variety of componentry. You also need different sizes. So each model may have six or eight variations depending on the needs of each patient."

Medical need should remain the overriding approval criteria, contends Bryce W.A. Docherty, a lobbyist for the California Orthotics and Prosthetics Association in Sacramento. An amputee should qualify for a cosmetically appealing device no more easily than someone who seeks elective cosmetic surgery or who wants a brand name -- rather than a generic -- prescription.

"The COPA position is that all medically necessary prostheses should be covered," Docherty said. "But for anything above and beyond that, we wouldn't oppose reasonable co-pays and deductibles similar to all other benefits provided by an insurer."

Nattress agrees but argues that the system should allow case-by-case exceptions that distinguish between medical necessity and functional necessity.

Insurers say not everyone needs the most expensive devices and they try to match each patient with cost-effective equipment prescribed by his or her doctor that meets the criteria of medical necessity.

"In today's world, there are probably dozens of new treatments, services and devices employers are struggling to incorporate into benefits," said Susan Pisano, spokeswoman for America's Health Insurance Plans in Washington, D.C., which represents the nation's insurers.

"Generally, what employers, policymakers, doctors and others will find most compelling and be willing to pay for is evidence that something is not only new but that it works better and more cost-effectively than an existing drug, service or device," Pisano said.

A January poll of 468 Amputee Coalition of America members revealed ongoing insurance reimbursement problems: 24 percent of responders reported that their private prosthetics coverage had been reduced during the past three years and 4 percent said it had been eliminated entirely. For 48 percent, there had been no change, and 24 percent said they have no private insurance.

"These are very telling numbers," said Meredith Goins, the Amputee Coalition of America's marketing and outreach coordinator. "It helps to show the percentages of people out there still not getting care."

Advocates define "access" as qualifying not only for a first prosthesis after losing a limb but also for a lifestyle-enhancing upgrade as well as the ability to visit a prosthetist of their choice for fittings and maintenance. Neither meets most insurers' criteria for reimbursement based on sheer medical necessity.

Technology continually improves, with lighter, more durable materials such as graphite becoming available. Very active amputees, especially athletes, put a lot of wear on the devices. And children need more frequent replacements to keep pace with their growth, he said.

Many insurers impose such low annual caps on coverage that otherwise active or athletic amputees cannot afford anything but basic artificial limbs. Restrictions as low as $2,500 or less a year are becoming standards in California, said Miguelez, the Advanced Arm Dynamics chief executive.

Some insurers also will readily reimburse for an amputation and secondary complications (including further amputation) stemming from inactivity, but they will limit or refuse to cover a prosthesis, Miguelez said.

"Access is getting worse every year," said Guy Savidan, a certified prosthetist/orthotist and president of Inland Limb and Brace Co., in Temecula. "As baby boomers retire, many who remain physically active could really benefit from state-of-the-art prostheses.

The coverage that employers now provide is much more likely to include cost sharing by the employees such as 20 percent to 50 percent co-insurance or deductibles for many services, as opposed to the small co-payments more typical of managed-care plans in the 1990s, said Pisano, the America's Health Insurance Plans spokeswoman.

"We purchase in large volume and pass discounts on to our members," said Jennifer Resch-Silvestri, spokeswoman at Kaiser Permanente Medical Center, Fontana.

A plan with minimal loss-of-limb coverage will cost much less than one with full coverage. Few people figure at the time they sign up that a catastrophic amputation will ever happen to them. But the reality is troubling.

About 1.8 million Americans are living with limb loss, and more than 185,000 amputations are performed each year -- a toll expected to increase substantially as the population ages. More than 65 percent of amputations performed on people age 50 and older are due to diabetes and peripheral vascular disease.

Limb loss doesn't affect just the aged. Every day in the United States, children are born with missing limbs, and teenagers suffer amputations as a result of accidents or cancer.

One of Savidan's clients, Michael Hanson, 17, of Murrieta, was born without a tibia in his left leg, which led to the amputation of his leg above the knee in early childhood.

"We can't mortgage the house to pay for a C-Leg," said Janice, who is divorced. "But he's been able to get along on what insurance will pay for."

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