Blue Cross Blue Shield denies coverage for Lockport woman's robotic arm, calls it 'experimental'
CHICAGO (WLS) -- While medical breakthroughs can change lives for the better, the ABC 7 I-Team found that access can be denied when innovative devices or treatments aren't covered by insurance.
It's because the innovations could be considered "experimental," including high tech robotic arms like the one a local woman desperately wants. She reached out to the I-Team when her insurance company denied her access to something she believes will change her life.
"Is your hand a luxury?" Rochelle Skaggs asked. "If you lost it, would you want it back?"
Skaggs, who was born with partial limbs, is a construction project engineer. Her new prosthetic legs have ankle joints, and she hopes to have better functionality of her left arm.
"I would be able to come out here with my iPad or my laptop and hold something and be able to write, even just a notepad or a clipboard," she said.
The solution, according to her and her prosthetic practitioner, is a $90,000 high-tech mechanical arm.
"There is no way I could pay for it out of pocket in my entire life," Skaggs said.
Her insurance provider, Blue Cross Blue Shield, denied her coverage, saying the arm is experimental. Skaggs said another "clamp-like" device is what insurance reps said may get approved instead.
"So I was born with amniotic band syndrome, it's a condition that happens about midway through pregnancy, basically like little rubber bands that wrap around the appendages of arms, legs, things like that and it just prevents growth, um, so it affected all four of my limbs," she explained.
Her prosthetic practitioner said the mechanical arm would be life changing.
"The individual five digits that actually move -- I would be able to straighten my hair and not burn myself, I could cook dinner and be able to open packets over a boiling pot without catching my hair on fire," she said. "Things you don't think about, tying my shoes this morning."
Tying her shoes usually takes a long time. Skaggs showed the I-Team how much faster and faster and easier it is with the robotic device.
"I was able to tie my shoes 100 times faster than I've ever been able to tie them in my whole life," she said.
"Because she hasn't had something like this in 27 years, and she's starting to feel the effects of it," said Tony Gutierrez of Bionic Stop Ahead, who fitted Skaggs with the new arm. "She's been in therapy for the last couple of months for lower back, shoulder and hip pain."
Gutierez and Skaggs believe that the device would actually save the insurance company later, preventing further care for arthritis.
"I could do so many things and not affect my shoulders, and my elbows, and the muscles in my arms. It goes back into my shoulder blades and the muscles in my back because I do things so altered," she said.
And the problem, she believes, goes well beyond herself as a specific patient.
"Absolutely it's a nationwide issue," said Skaggs.
Dan Ignaszewski represents the Amputee Coalition and said most insurance companies are denying high tech prosthetics.
"It tends to skew that way. They are more likely to approve a body powered device, for example, than they are something that has electrical components or things like that. It may be more costly but provides significantly more functionality and independence," he said.
And it goes beyond prosthetics. University of Illinois at Chicago public health expert Anthony LoSasso said whether it's a new procedure or piece of equipment, most carriers only cover the basics.
"It's a bigger, broader issue. It is a common issue -- all health policies have some types of limits. So they cover services, equipment, medicines that are reasonable and necessary and that tends to omit things that are considered experimental or investigational," he said.
As for Skagg's dispute, Blue Cross Blue Shield told the I-Team, in a statement: "...a prostheses with individually powered digits, including but not limited to a partial-hand prostheses, is considered experimental, investigational and/or unproven and that is determined by Medical policies... based on peer-reviewed scientific literature, criteria developed by specialty societies and from guidelines adopted by other health care organizations."
"They talk about the item, the prosthesis hand, as being a luxury and it's not needed," said Skaggs.
Their view of her prosthetic hand as a luxury doesn't make her feel good.
"Well you're born with your hand, why can't I have a hand?" she wondered.
Blue Cross Blue Shield also said, like all patients, Skaggs has the right to appeal. Her practitioner did, listing and citing what he calls evidence showing that the arm is not experimental or investigational, and also saying, "Multi-articulating digit prosthetic hands have been an established technology since 2007."
The Illinois Department of Insurance upheld the insurance company's denial.
The I-Team asked Skaggs what she would like to say to the person at the insurance company who said she doesn't need the arm.
"I would like them to go a day using only four fingers or even no hand, tie it behind your back for an entire day and let me know how your day goes," replied Skaggs. "If you could do that and see the struggles people go through when they are missing a limb you would see the difficulties and rethink the approval process."
Health experts say companies behind technologies also have a responsibility to first get groundbreaking treatments and equipment to patients at a lower cost because once the devices are documented as being used in the real world, they may not be considered "experimental."
If you're dealing with a denial you can try to make a case to your insurer that the new treatment will save them money in the long-run.
UIC SCHOOL OF PUBLIC HEALTH TIPS
- You can try to look for a better policy that covers experimental treatment, but experts say it's not likely you will find one
- Read your insurance's policies on what's considered "experimental" or "investigational"
- There may be wiggle room if you are suffering from a terminal disease, which may give you easier access to experimental treatments
- Make a case and appeal to your insurer that the treatment or device will save the insurer money in the long run
- Get evidence together about what treatments or devices you have already tried
