Eight-year-old Darrius Simmons is climbing the walls in his Warren home, his legs stuck on either side of the white walls as he manages to get about a little over a foot above the red carpet below.
"Hold on, I can go higher. I almost had it," he says, stumbling and raising his leg to a 90 degree angle.
Without a prosthesis, Simmons, who has tibial hemimelia with congenital deformities in both of his legs, climbs walls and does front flips on the trampoline. With a prosthesis, which he has worn since age two, he is able to maintain a normal life.
However, because of an insurance coverage change, paying for a new prosthesis for her son will be more challenging for Tamara Simmons. As of August 2007, Simmons' insurance covers only $4,000 per year for prosthetics. On average, prosthetic care costs her $16,000 to $17,000.
Simmons said she got the wind knocked out of her when she found out about the coverage cap. "How do you put such a small cap on something when it's so expensive?" she said.
In the past, Simmons' insurance paid for 80 percent of care, while Medicaid paid for the remaining 20 percent. The insurance cap will force Simmons to reapply for Medicaid, which she says she is not sure she'll get, since she now has two dependents instead of three. She will try every avenue for insurance coverage, she said, and "just search, seek and pray."
Simmons is not alone in her struggle with insurance coverage for prosthetic care.
Though Sally Davis' insurance company said she could get around with her above knee prosthesis, a passive mechanical knee, the Sharpsville, Pa., resident has fallen numerous times and broke her wrist in June 2007. The C-Leg's stumble recovery mechanism would help prevent her falls, yet Davis' insurance company won't provide the level-three coverage necessary for the prosthesis.
Davis said she refuses to be the type of person who sits in a wheelchair and does nothing the rest of her life.
"I don't care if I am 67. I'm not dead," she said.
Davis' and Simmons' plights are part of a growing problem among amputees who must deal with insurance companies with picky coverage plans.
More than 185,000 new amputations are performed each year in the U.S., and a survey conducted by the Amputee Coalition of America in 2007 found that over the last four years prosthetic coverage had reduced for 29 percent of participants.
The Amputee Coalition of America is heading an effort to pass legislation to make insurance companies cover prosthetic care as they would any other medical service. Eleven states have passed bills, and the ACA is working to advance legislation in 29 other states, including Ohio. On March 13, the Prosthetic Parity Act was introduced into Congress.
Morgan Sheets, national advocacy director of the Amputee Coalition of America, attributes the change in coverage to cuts many insurance companies made in 2000 to durable medical equipment, the category prosthetics falls under. In the years since, it became increasingly common for insurance companies to put restrictions or caps specifically to prosthetics as a "cost saving measure."
Despite the cost saving measure, Sheets maintains that individuals purchase insurance for catastrophic events, the "what ifs" in life.
"What can be seen as more traumatic than the loss of a limb?" Sheets said.
In a written statement, Anthem Blue Cross and Blue Shield stated that they determine whether procedures, devices and technology are medically necessary by "relying on scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community as well as evidence that the procedures, devices and technologies may improve health outcomes and will be as beneficial as any established alternative."
Anthem stated that they routinely evaluate and update medical policies to incorporate new scientific information.
In terms of coverage, they stated they consider prosthetic devices medically necessary "when several criteria have been met, including a physician prescription and the member's ability to use the device. Maintenance and repair of medically necessary prosthetic devices are also considered medically necessary when the effectiveness or functionality of the artificial limb is impacted; are recommended by the manufacturer and are performed by a prosthetist; and if adjustments are necessary because of wear and tear or a change in the patients condition."
For Kevin Walters, of Reynolds, Pa., a change in the way health insurance companies operate is a must.
"I think it's completely flawed all across the board," Walters said of health insurance.
Walters said patients should be treated as individuals.
"I don't think you can put a monetary value on somebody's abilities," he said.
The insurance process is impersonal, he said, and a liaison should communicate between the insurance agency and the patient.
Walters had his own negative experience with impersonal insurance coverage.
Due to insurance policy stipulations, the 27-year-old spent two years primarily depending on others when traveling outside his home.
Finding himself without insurance coverage at the time of a 2003 motorcycle accident which left him a bilateral above knee amputee, Walters turned to Medicaid, which wouldn't pay for a powered wheelchair. He was left with a traditional wheelchair. Stuck in the house that summer, he was grateful when someone would stop by and take him to the park.
During that time, Walters said, he was angry at the whole insurance process, and he wondered who got to determine what his quality of life should be.
"There's just the dollar signs standing between you and your goals," he explained.
Two years after his injury, Medicaid deemed Walters "permanently disabled," and Medicare became his primary insurance. After two years, a powered wheelchair became his.
Walters would ride into town on his power chair, shooting hoops at the local high school's outdoor basketball court with friends. He would ride to and from the video store that he owned. On a fully charged battery, his chair could take him 30 miles.
Though he has received C-Legs, Orthotics and Prosthetics Rehabilitation Engineering Centre footed the requisite 20 percent of the bill due to Walter's 80-20 reimbursement plan.
John Billock, specialist in prosthetics and orthotics at Orthotics and Prosthetics Rehabilitation Engineering Centre, said this is something the company has always done in situations such as Walters'.
Besides the typical reimbursement plan, other stipulations are involved with prosthetic care.
Insurance agencies can put a cap on prosthetic care, or they can have a "one per lifetime" stipulation, Billlock said. Other agencies won't cover certain technologies.
As far as Billock is concerned, the insurance agencies are just trying to improve their bottom lines. He, too, believes change is in order.
"I think the insurance companies are trying to minimize their reimbursements as much as they can," he said.
Billock said that his company continues to move forward with patients' prosthetic care while waiting for insurance approvals, since delays can be detrimental to patients, emotionally and physically.
BREAK OUT BOX
2008 average prosthetic fees
The average range of prosthetic fees listed below cover the total cost of prosthetic care for an individual with the levels of amputation indicated The fees include the initial evaluation and consultation with the referring physician, regarding the type of prosthesis recommended, as well as the fitting assessment and initial training procedures associated with the design and development of their prosthesis. Each prosthesis is custom designed, with regards to it fitting and the components utilized in its design, to meet the individual's vocation and/or avocational needs.
Below Knee Prosthesis: $7,000 to 20,000
Above Knee Prosthesis: $15,000 to 50,000
Below Elbow Prosthesis: $10,000 to 35,000
Above Elbow Prosthesis: $15,000 to 95,000
Source: John Billock, specialist in prosthetics and orthotics at Orthotics and Prosthetics Rehabilitation Engineering Centre in Warren
On June 24, Kevin Walters walked independently for the first time since a May 2003 motorcycle accident robbed him of his legs.
"If they can do it, I can do it," Walters repeated to himself while watching a video of someone else walking independently on prosthetics like his own.
After closely studying the video, Walters went into the hallway at Orthotics and Prosthetics Rehabilitation Engineering Centre in Warren, and walked up and down the hallway three times.
Understandably, the accomplishment meant a lot to Walters.
"It was definitely a two-liter bottle of bliss," Walters said.
While Walters' C-Leg type prosthesis has made it possible for him to walk again independently, the road in getting there took four years.
Walters received his first above/knee prosthesis in Pittsburgh, a single axis hydraulic prosthesis with a fixed foot.
After reading the Amputee Coalition of America's bi-monthly magazine, "In Motion," Walters spotted an advertisement for a prosthetic facility in Long Island, N.Y. He ended up staying there for 10 days to get a different style prosthesis with feet that weren't fixed.
Though Walters also got new sockets made in Long Island, when he started training with them at home, his residual limbs had shrunk. The sockets no longer fit.
The problem brought Walters to three different prosthetic facilities: Pittsburgh and Erie, Pa. and Warren to see John Billock at Orthotics and Prosthetics Rehabilitation Engineering Centre.
Walters was on a quest to find a prosthesis that was more comfortable. The trim line for his prosthesis went all the way up to his back side, he had to sit on his prosthetics. Besides being uncomfortable, he slid off of chair easily.
The higher trim line complicated clothing as well.
If he wore a prosthesis with a lower trim line, Walters could simply wear wide leg jeans instead of jeans that were four to five sizes too big on him.
Ultimately deciding on the Erie facility, Walters and a prosthetist attended a seminar in Orange County, Calif. about a socket design with a lower trim line. He stayed there for five days and returned home with one leg finished.
Once in Erie, he began the tedious fitting process for the other leg. After a month of one-week appointments, Walters ran into another jam. His Erie prosthetist had had her child, which brought Walter's fitting to a halt.
Returning to Warren, Walters worked with Billock, who eventually fitted him with C-Legs.
After his accomplishment, which Walters describes as "better than Cedar Point, by far," he maintains that much of walking is more mental than physical.
"That was all head and heart," he explained.
Walters plans to make a future out of helping others like him, and will attend Youngstown State University in the fall for psychology and pre-physical therapy.