April 2025 — As U.S. health insurers increasingly deny coverage for advanced prosthetic limbs, amputees and advocates are calling out a growing disparity in medical necessity standards — particularly when compared with other orthopedic treatments such as joint replacements.
Michael Adams, a 51-year-old cancer survivor from Colorado, recently faced this dilemma. Although he enrolled in a health plan that listed prosthetic limb coverage, his insurer refused to replace his microprocessor-controlled knee — a $50,000 device his doctor deemed essential for safety and mobility. Only after an appeal did the insurer reverse the decision, citing an “administrative error.”
“The electronic prosthetic knee is life-changing,” Adams told KFF Health News. “It would be like going back to having a wooden leg.”
Microprocessor-controlled prosthetic knees, which help users walk on varied terrain and prevent falls, have been available for decades. Yet insurers often deny them on grounds they are “not medically necessary” or are “experimental,” despite long-established clinical use.
A Broader Systemic Issue
In contrast, Americans with joint conditions typically face no such denials. According to the U.S. Agency for Healthcare Research and Quality, 1.5 million hip or knee replacements were performed in 2021 alone — many at costs similar to or exceeding advanced prosthetics.
To many in the amputee community, the unequal treatment amounts to systemic discrimination.
“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” said Dr. Jeffrey Cain, former board chair of the Amputee Coalition, in an interview with KFF Health News.
While some states — including Colorado — have enacted “insurance fairness” laws mandating parity for prosthetic coverage, those protections only apply to state-regulated health plans. Over half of privately insured Americans are in employer-sponsored or federally regulated plans, which are exempt.
According to data from the Amputee Coalition and health analytics firm Avalere, roughly 2.3 million people in the U.S. live with limb loss. Yet fewer than 50% are prescribed prostheses, with cost and denial of coverage cited as major barriers.
Medicare and Financial Hardship
Medicare covers prosthetic limbs at 80% coinsurance, but even then, beneficiaries face significant out-of-pocket costs. A 2023 Government Accountability Office (GAO) report found that only 30% of Medicare beneficiaries who lost a limb in 2016 received a prosthesis within the following three years.
“No matter your coverage, most people have to pay something on that device,” said Ashlie White, Chief Strategy Officer at the Amputee Coalition. “Some people end up on payment plans or take out loans.”
White noted that the Consumer Financial Protection Bureau recently proposed a rule to prevent repossession of medical devices, including prosthetic limbs — a real risk for those unable to pay.
A Personal Cost
Leah Kaplan, a 32-year-old public worker from Spokane, Washington, was born without a left hand. Her insurer denied coverage for a myoelectric prosthetic hand — a $46,000 device her doctor prescribed — deeming it not medically necessary. Despite multiple appeals, she remains without the device.
“A prosthetic hand is not a luxury,” Kaplan told KFF Health News. “I’ve been waiting for this for so long.”
Until her appeal to an independent state-certified review board is resolved, the prosthesis remains in limbo.
References & Source Attribution:
- KFF Health News (Rae Ellen Bichell, original reporting)
- U.S. Agency for Healthcare Research and Quality (AHRQ)
- Government Accountability Office (October 2023 report)
- Amputee Coalition, Avalere Health
- Consumer Financial Protection Bureau (proposed 2024 rule)
