Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Myocardial Infarction

Treatment: Zoll Life Vest - Code K0606

The insurer denied coverage for Zoll Life Vest - Code K0606

The denial is overturned

Reviewer #1:

This is the case of a patient that presented to the hospital with chest pain and dyspnea on exertion.  Emergency Medical Service (EMS) records prior to arrival at the hospital note that the patient was found to be in a wide complex tachycardia at a rate of 150 beats per minute consistent with sustained ventricular tachycardia (VT).  Subsequent work up revealed triple vessel coronary artery disease (99% (percent) right coronary artery, 100% mid- left anterior descending artery, 90% first diagonal artery, 90% first, second and third obtuse marginal arteries).  Left ventricular ejection fraction was noted to be severely depressed with a 4x3 centimeter (cm) posterior wall aneurysm.  The patient underwent coronary artery bypass graft surgery. Impella, left ventricular assist device, was utilized to augment perioperative cardiac output. The operative report specifically noted that several shocks for ventricular tachycardia were delivered following completion of bypass grafting. The patient's post-operative course was complicated by mediastinal bleeding requiring reoperation.  Ultimately the patient was discharged on medical therapy and with a wearable life vest defibrillator. 

External life vest defibrillator therapy was medically necessary in this patient. This patient presented with sustained VT, severely depressed left ventricular ejection fraction (LVEF), large posterior wall aneurysm and heart failure. Sustained ventricular tachycardia and a large posterior wall aneurysm place this patient at a high risk of recurrent sustained ventricular arrhythmia during the post operative period.  The Sudden Cardiac Death in Heart Failure (SCD-HeFT) trial clearly demonstrated that patients with a depressed LVEF and no documented sustained arrhythmia have a significant risk of sudden cardiac death and benefit from ICD (Implantable cardioverter-defibrillator) therapy (1).  Wearable life vest defibrillator therapy provides such protection while physicians determine whether treatment will result in an improvement in cardiac function (2). Ultimately, if medical therapy fails to result in an improvement in this patient's LVEF and functional class then an implantable device would be recommended.  External life vest defibrillator therapy provides protection from sudden cardiac death while physicians determine whether treatment will result in an improvement in cardiac function. This patient's severely depressed LVEF, and ventricular arrhythmia place them at high risk for sudden cardiac death during titration of anti-congestive therapy. Guideline statements from the Heart Rhythm Society/American Heart Association and the American College of Cardiology specify that wearable life vest defibrillator therapy should be utilized during periods when patients are at risk of sudden cardiac death and require further cardiac workup/treatment (3,4,5). In conclusion Wearable defibrillator therapy is medically necessary in this case.

In summary, the denial of Zoll Life Vest - Code K0606 and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.