> At a Glance
> – Aetna initially refused to cover a new partial-foot prosthesis for 21-year-old Gabrielle Guerrero, calling it “not medically necessary.”
> – Her mother paid $7,500 on a credit card so Guerrero could walk at her December college graduation.
> – After a second denial-and repeated media questions-Aetna reversed course and reimbursed the full amount.
> – Why it matters: Insurance denials for prosthetic devices are routine, forcing patients to choose between debt or mobility.
Gabrielle Guerrero, 21, needed a replacement partial-foot prosthesis after her first one-issued at age 15-literally fell apart. Aetna first said no, then yes, once new clinical details reached the insurer.
The Crash and the First Denial
At 15, Guerrero was riding in an off-road vehicle that hydroplaned and flipped. Her left foot was trapped; two surgeries later, doctors amputated part of the foot. She has worn a custom prosthesis ever since.
Six years of daily wear left that device crumbling. Two toenails were gone, the back tore open, and the fit loosened. Aetna had fully covered the original, but a September denial letter said the new request was:
- Improperly coded
- For “appearance, comfort, or convenience,” not medical need
> Gabrielle Guerrero: “I don’t understand how comfort isn’t medically necessary.”
Deadline Pressure and a Credit Card Swipe
Guerrero targeted her December college graduation as the day she wanted to walk pain-free. With the ceremony eight days away and no approval in sight:
- Her mother charged $7,500 to a credit card
- The prosthetist completed the device after six fitting visits
- Guerrero crossed the stage wearing the new foot
Aetna told News Of Philadelphia that during a peer-to-peer call the prosthetist “was unable to answer fundamental questions” and that the device might slip off and cause falls.
Aetna Reverses Course
The day after graduation, Aetna issued another denial. Several days later, after receiving “more critical information,” the company announced:
> “The insuring plan sponsor for Ms. Guerrero has agreed to grant coverage.”
Guerrero’s mother was reimbursed the full $7,500 just before the holidays.
| Stage | Outcome |
|---|---|
| 1st request | Denied-coding and necessity issues |
| 2nd review | Denied-functionality questioned |
| Post-review | Approved-coverage granted |
A Pattern Across the Country
Insurance denials for prosthetic limbs are commonplace, according to the Amputee Coalition:
- At least 25 states have laws mandating prosthetic parity with Medicare
- Medicare generally covers devices that restore function with a 20% copay
- Nearly every patient will face a denial at some point
> Nicole Ver Kuilen, Amputee Coalition: “It’s not a matter of if you’ll be denied, but when.”
Key Takeaways
- Aetna’s initial refusal forced a family to pay $7,500 out-of-pocket
- Persistent advocacy-and media attention-led to a full reversal
- State parity laws exist, but gaps leave many without coverage
- Travel distances to qualified prosthetists can exceed 100 miles
Guerrero hopes her story encourages others to keep pushing:
> “Never give up, because eventually they’ll say yes-or I hope so.”
