If you would like your prosthetic leg to be covered by insurance or Medicare, then this article was written for you.
We are going to show you the exact format we use to help people everyday get their prosthetic leg covered.
Is this a guarantee of payment? No. – Unfortunately, it is not.
It is truthful information however, so you can read the article and choose the best options for yourself.
Ok. Here is how it is done at prosthetic companies near you everyday.
1.) You Need a Prescription
Picture of an Amputee Learning To Walk With a New Prosthesis
A prescription is otherwise referred to as an Rx. The medical doctor, nurse practitioner or physician assistant writing that Rx needs to say what kind of prosthesis you need. For example, a sample script might read : Left below the knee prosthesis with a K3 foot. Diagnosis = PVD.
The Rx is the start of the paper trail, if you will. It is the first thing that is given to prove medical necessity for your prosthesis. It is definitely a good start to get a signed and dated Rx, but it not the only thing you will need to get your prosthesis covered unfortunately. To learn more lets jump to the next section.
2.) Notes From The Medical Doctor, Nurse Practitioner or Physician Assistant
The person who wrote you the prescription for the prosthetic leg should ideally be putting certain stuff in their notes to augment the need for the prosthesis. Unfortunately, some bad eggs in the past who wanted to make money off of prosthetics stole prescription pads and would forge signatures so everyone and their brother needed a prosthetic leg. Sad, but true. So, as a result, the insurance companies and Medicare require a little more certainty to really know the claim is legitimate.
Meaning, in the body of the medical doctor’s, PA’s or NP’s notes their needs to be some wording that augments the Rx. This is ideally done well before treatment has formally started. It would need to augment whether you truly want to walk again. Whether you have the potential to rehabilitate and what K Level you are or have the potential to return to in a short period of time. Also, a description of the prosthetic components required definitely helps to get you covered. This is what is needed in general.
You will also need to be seen by a licensed prosthetist who will not only provide great service and a sound leg, but they will also need to do their notes per Insurance / Medicare’s guidelines.
3.) Your Deductible 
Do you have a high deductible, low deductible or neither?
No matter how good the notes are, no matter how awesome the Rx is written, you still need to come face to face with your deductible. It is what it is, whether we like it or not it is there as a real hurdle.
If you have a $10,000 deductible that has not been met at all, the prosthetic company could ask you for a payment in full or to get on a payment plan. Ideally, people in a “perfect world” would have no deductible, but with the rising costs of insurance these days we can understand why people choose the higher deductible plans.
4.) Medicare
As a general rule of thumb, Medicare will pay for a prosthetic leg, if all of the requirements are met. As you now know, notes are required from the clinician, an Rx is required and you will need to be seen by a licensed prosthetist.
In general, Medicare covers prosthetics at 80 percent of their allowable. The prosthetist does not make up the price. Medicare and insurance tells the prosthetist what the reimbursement levels are for particular components.
Perhaps you have heard of the 80/20 rule.
This is where Medicare covers the first 80 percent and you or your secondary insurance picks up the remaining 20 percent of the cost.
5.) Insurance
If your insurance covers things at 100 percent then you can be free of any financial responsibility, besides paying for the insurance itself. Not a bad deal on the side of the consumer. As stated above however, you now know that if you have Medicare as primary you might have to come up with a portion of the cost if your insurance does not pick it up. It all depends on the kind of a plan you have and its coverage criteria.
6.) Asking For Help From The Prosthetic Company
A reputable prosthetic company will help you find out what your coverage levels are for the prosthetic leg. Just to let you know this is done as a free service! So take advantage of that. You will have the opportunity to ask Medicare or your insurance yourself whether you are covered, but sometimes you need L codes to confirm coverage.
If you do call and try to determine coverage yourself, make sure to get reference numbers if possible because it helps to track progress as you move along.
We hope this information helped you.
Good luck!