A Texas amputee has revealed she was left in tears when her insurance company denied a claim for a replacement prosthesis ahead of her college graduation ceremony, according to an NBC report.
Gabrielle Guerrero, from the Fort Worth suburb of Burleson, had her left foot partially amputated at the age of 15 following an off-road vehicle accident.
Now 21, Guerrero feared that she would be unable to walk with her classmates during graduation from Texas A & M in December unless her mother racked up $7,500 in credit card bills to fund a new prosthetic foot.
“When I walk barefoot on hard floors, it’s very, very painful, I can feel the callous, the pressure on it,” Guerrero, who lost all of the toes on her left foot and half of the foot itself following the accident, which left her requiring two surgeries and a two-week hospital stay, told NBC. “So when I wear that prosthetic, it takes that pressure off.”
However, after six years of use, her original device had worn down and was scarcely usable, Guerrero said. It had gotten to the stage where it was “disintegrating,” according to Guerrero, with a large tear down the back and two missing fake toenails.
While her first prosthesis had been covered by insurance giant Aetna, the replacement claim was denied by the company. Aetna sent Guerrero a letter in September, stating that the claim had been incorrectly “coded” and that it did not qualify for coverage as it was for “appearance, comfort or convenience,” – and therefore not medically necessary.
“I was honestly just in tears because of the anger,” Guerrero added, but worse was to follow with a second denial just over a week before the graduation ceremony.
So that Guerrero could take part fully in graduation, her mother paid the $7,500 for the prosthetic, which had been custom made for her but could not be released until the fee had been met.
Following graduation, an Aetna told NBC 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.” Guerrero’s prosthetist did not respond to NBC’s request for comment.
Days later, however, Aetna changed its decision and agreed to cover the cost of the item after receiving new “critical information.” Guerrero’s mother therefore received her money back.
Amputee support groups say that denial of coverage for prosthetic equipment is a common issue faced by the community.
“The amount of denials that our community faces is prolific, and it’s not a matter of if you’ll be denied, but when,” Nicole Ver Kuilen, director of impact campaigns for the Amputee Coalition, told NBC.
More than 25 states have legislative regulations mandating that state-sourced insurance plans offer equal prosthetic coverage to Medicare. In most cases, Medicare covers devices that replace a body part and require a 20% copay.
Dr. Jerry Grimes, a foot and ankle orthopedic surgeon at Texas Tech Physicians, described prosthetics as “an art.”
“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.”
Guerrero’s new prosthesis required six visits, the NBC report said, with four trips needed to ensure proper fitting.
“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 added.
Guerrero urged others faced with similar denials not to give up, but to pursue claims strongly.
“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.”