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Anthem Prostheses Coverage Class Action Lawsuit Overview:
- Who: Lacy Atzin and Mark Andersen filed a class action lawsuit against Anthem, Inc.
- Why: Plaintiffs allege Anthem denied coverage for microprocessor-controlled lower limb prostheses for persons with lower-limb loss.
- Where: The class action lawsuit was filed in California federal court.
Anthem, Inc. has settled a four-year lawsuit claiming that it wrongfully denied coverage for microprocessor-controlled lower limb prostheses.
As laid out in a notice of motion and the motion for preliminary approval of class action settlement, Class Members who paid out of pocket for microprocessor-controlled knees and foot-ankle prostheses can make claims for reimbursement to the extent those out-of-pocket payments have not been paid by other insurance, Medicare or other reimbursement sources for which the Class Member owes no reimbursement obligation.
Class Members who have not yet paid out-of-pocket for microprocessor-controlled knee or foot-ankle prostheses, and are currently covered by Anthem, can submit a new request for the device according to the terms of their existing Anthem health plan.
Class Members who have not yet paid out of pocket for microprocessor-controlled knee or foot-ankle prostheses, and are no longer covered by Anthem, cannot submit a new request. They release no claims and are free to make a claim with any health plan they now have or will have in the future, including Anthem. All claim reimbursement determinations shall be made within 90 days.
Anthem ‘Erroneously’ Denied Prostheses Coverage to People With Lower-Limb Loss, Class Action Lawsuit Claimed
Lead plaintiffs Lacy Atzin and Mark Andersen filed the lawsuit in September 2017, alleging that Anthem wrongfully denied claims for microprocessor-controlled prostheses.
The complaint alleged that Anthem developed and used an internal coverage guideline, the Anthem Medical Policy on Microprocessor Controlled limb Prosthesis, Policy No. OR-PR.00003, to deny claims for microprocessor-controlled lower limb prostheses. Concerning microprocessor-controlled knee prostheses, Anthem used erroneous criteria in the Former Medical Policy to deny claims as not medically necessary, the lawsuit alleged.
To receive coverage, claimants needed to prove they had adequate cardiovascular reserve and cognitive learning ability to master the higher-level technology and to allow for faster than normal walking speed, the ability to ambulate faster than their baseline rate using a standard swing and stance lower extremity prosthesis, a documented need for daily long-distance ambulation (for example, greater than 400 yards) at variable rates and a demonstrated need for regular ambulation on uneven terrain or regular use on stairs.
Plaintiffs alleged that these criteria were erroneous because they were predicated on a person with a prosthetic leg demonstrating the ability to master “a faster than normal walking speed” and doing it with a “standard swing and stance” device.
“While a microprocessor-controlled knee prosthesis may allow a person to walk faster, plaintiffs alleged this was only one of the benefits of the device and failed to recognize that they also allowed people to accomplish “normal” activities of daily living,” the motion states.
The plaintiffs also alleged the policy imposed unreasonable distance requirements and demands regarding “regular” use of uneven terrain or stairs while excluding the use of home or workplace stairs.
Effective Aug. 28, 2019, Anthem agreed to revise its medically necessity criteria. The new policy removed the erroneous speed requirement in the former policy. Instead, it provided that a person could qualify by simply having their provider attest that there was a reasonable likelihood of better mobility or stability with the microprocessor. It also revised the distance requirement so that if a person could show the need for the microprocessor device through regular daily home or office use, they did not also need to meet the distance requirement.
Has Anthem denied your coverage of microprocessor-controlled protheses? Let us know in the comments!
The plaintiffs are represented by Robert S. Gianelli and Joshua S. Davis of Gianelli & Morris and Conal Doyle and Stephen Beke of Doyle Law.
The Anthem Protheses Coverage Class Action Lawsuit is Lacy Atzin v. Anthem UM Services Inc. et al., Case No. 2:17-CV-06816, in the U.S. District Court for the Central District of California.
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One thought on Anthem Settles Class Action Lawsuit Over Coverage For Lower-Limb Prostheses
My son was denied for the microprocessor knew and ankle last month by Anthem.