Aaron Holm lost his legs when a car hit him as he helped a stranger change a tire.

Holm responded to his personal tragedy by learning to walk on artificial limbs and starting a nonprofit group to help other amputees. Now, Holm is learning a hard lesson in Washington politics as he leads an effort by Minnesotans to fight new federal rules on Medicare payments for prosthetics.

Holm says those changes could deny suitable treatment for many of those who have lost their lower limbs. The bureaucrats in D.C. have yet to take heed.

"I remain optimistic, but it fades as time goes on," Holm said. "Knowing how things work, if you don't press this, it will just fall into the cracks."

Holm, who is 49, traveled to Washington in August with seven other Minnesota amputees to participate in a protest of the rules that were announced in July. Nearly three months in, the rules remain on the books. The fact that the government has not yet implemented them is cold comfort.

The rules can be activated any time.

What's more, Holm and other amputees say the new restrictions have already had an impact on coverage. One big fear of amputees is that private health insurers have historically followed Medicare's lead in deciding what to cover. On Oct. 1, Minnesota-based UnitedHealthcare stopped covering some vacuum suspension systems that hold artificial legs on to bodies using suction.

UnitedHealth's new coverage limit mirrors a recommendation of the new Medicare rules.

UnitedHealth, the nation's largest health insurer, declined to explain exactly why it changed its coverage or to say whether the Medicare rules played any role in the decision.

"Our current policy provides prosthetic device coverage for amputees when the device meets required medical policy criteria," the company said in a statement. "If new scientific evidence becomes available, we will re-evaluate our medical policy."

Rob Rieckenberg, a 37-year-old amputee from Minneapolis, has already seen what limits to private insurance can do.

"I have a vacuum suspension socket," said Rieckenberg, who lost a leg 10 years ago after he was mugged and left on a train track where he was struck by a train. "My employer has group insurance with United. There's no way I can go on that plan. So I've had to buy an individual plan through Blue Cross. I'm paying five times as much for premiums because United doesn't have this coverage."

Meanwhile, Rieckenberg says he has to have a vacuum suspension because of the skin grafts on his stump. Another technology, he said, "would tear up my skin."

Holm and Rieckenberg think United's actions foreshadows coverage cuts in many services across the private health insurance market. Those cuts, they say, will leave amputees with artificial limbs that are more painful to wear and more exhausting to use.

The new Medicare policy and United's change of coverage are "just an easy way to cut costs," Holm said.

Charlie Kuffel, a clinician who fits amputees with prosthetics, concedes that artificial legs with vacuum suspension can cost $6,000 to $7,000 more than older technologies that use a long sock or a shuttle lock to secure prosthetics to the body.

But Kuffel, president of Arise Orthotics and Prosthetics in Blaine, said the snugger connection and blood circulation provided by vacuum suspension reduce medical complications like pressure sores and swelling that lead to more insurance payments for office visits to doctors and clinicians.
Vacuum suspension also improves an amputee's gait, allowing him or her to walk more naturally and farther with less trauma and to avoid falling, Kuffel added.

Democratic Sen. Amy Klobuchar and Republican Rep. Erik Paulsen of Minnesota have entered the battle to change the new coverage rules but have yet to see their efforts succeed.

Klobuchar and Sen. Dan Coats, R-Ind., co-chair the Senate Medical Technology Caucus. On Sept. 16, the pair wrote to Andy Slavitt, head of the Centers for Medicare and Medicaid Services, saying implementing the new prosthetics rules "would restrict access to modern prosthetic care for approximately 150,000 Medicare beneficiaries in need of lower limb prosthetics."

In an interview, Klobuchar said she believed there is "room for movement" in the new Medicare policy.

Paulsen co-chairs the House Medical Technology Caucus with Rep. Anna Eshoo, DFL-Calif. On Sept. 9, they wrote to Health and Human Services Secretary Sylvia Burwell saying the rules "could set prosthetic care back decades" and "will cause patients to live with prosthetic technology that is outdated."

Among the problems that Holm and other amputees have highlighted is a new policy that eliminates Medicare coverage for certain prosthetics if a patient uses a cane, crutch or walker. Another policy restricts coverage of certain prosthetics if they don't give patients "the appearance of a natural gait."

"The main concern is that the policy applies a one-size-fits-all approach," Paulsen said in an interview.

If Medicare won't change the policy, he added, "we might have to have a legislative solution."
Rieckenberg is all for that.

"Amputation is like a fingerprint," he said. "Every one is different."
Jim Spencer • 202-383-6123