Plaintiff Lacy Atzin lost her leg above the knee from cancer at the age of eleven. She now has five children and her prosthetist says that she needs a prosthetic leg with a microprocessor. Anthem, her medical insurer, says that she doesn’t need it. Plaintiff Mark Andersen lost both feet after a boating accident. Since he owns a moving and storage company, his prosthetist says that he needs a foot-ankle prosthesis with a microprocessor. Anthem says no.
The class for this action is
Defendant Anthem is one of the largest health insurers in the US, with nearly 40 million subscribers. The complaint claims that its medical plans are governed by ERISA. Defendant Anthem UM is Anthem’s claims administrator. The two companies together develop Medical Policies and make decisions on which claims are approved and which are denied.
One of their policies is the denial of claims for microprocessor-controlled lower limb prosthesis, the complaint says, on the grounds that they are “investigational and not medically necessary for all indications.” The complaint disagrees.
Lower-limb prostheses come in two kinds: above the knee and below the knee. According to the complaint, makers of these prostheses have used microprocessors for decades, along with sensors, software, a resistance system, and batteries. The complaint says that these systems monitor the person’s gait cycle and environment, such as changes created when a person walks on a different surface, goes up a hill, or changes speed, then adjusts the device’s resistance to bending and straightening to adapt. The complaint claims these have now become standard.
Anthem has two barriers to covering them: that the prostheses are still “investigational,” and that they are not “medically necessary” for all. Anthem’s criteria for necessity for a microprocessor knee prosthesis requires that the person has “a documented need for daily long distance ambulation (for example, greater than 400 yards) at variable rates” and that the “individual has a demonstrated need for regular ambulation on uneven terrain or regular use on stairs.” The guidelines specifically state that use within the home or community or for home or workplace stairs is not sufficient to create a necessity. Anthem is even less favorable to microprocessor foot-ankle prostheses.
However, the complaint claims that microprocessor prostheses increase safety and stability, reduce stumbles and falls, lessen the energy it takes to move the artificial leg, decrease discomfort and pain, and aid walking at a variable rate, over varying terrain, or up or down stairs. It’s difficult to see how this is not necessary for, say, the owner of a moving and storage company with two artificial feet.
The complaint asks for clarification of rights under an ERISA plan and alleges denial of benefits and breach of fiduciary duties.