Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure

Treatment: An automatic external defibrillator

The insurer denied coverage for an automatic external defibrillator

The denial is overturned

This patient presented to the hospital after Holter monitor revealed frequent runs of non-sustained ventricular tachycardia (NSVT). He was noted to have an irregular heart rhythm several weeks earlier during screening colonoscopy. Subsequent cardiac evaluation revealed a depressed left ventricular ejection fraction (LVEF) of 25%. Guideline directed medical therapy was initiated and a Holter monitor to assess ventricular arrhythmia was ordered. Following review of Holter electrocardiogram (ECG) tracings demonstrating frequent runs of NSVT the patient was instructed to seek evaluation in the emergency department. Upon arrival to the hospital, vital signs were stable and physical examination was without significant abnormality. 12 lead ECG revealed frequent multiform ventricular premature complexes (VPCs).

Repeat echocardiogram revealed an LVEF of 17%. Cardiac catheterization revealed normal coronary arteries with a severely depressed LVEF and severely elevated filling pressures. Cardiac magnetic resonance imaging (MRI) revealed an LVEF of 14% with mid myocardial delayed gadolinium enhancement. Findings were consistent with non-ischemic heart failure with reduced LVEF. As frequent ventricular ectopy and NSVT were not suppressed with escalating doses of beta blocker therapy, amiodarone was initiated. The patient was prescribed an external LifeVest defibrillator while guideline directed medical therapy was titrated.

The insurer did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with severely depressed LVEF and new onset heart failure. Moreover, he had frequent pleiomorphic ventricular ectopy and NSVT on Holter monitor. The Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) clearly demonstrated that such patients have a significant risk of sudden cardiac death and benefit from implantable cardioverter-defibrillator (ICD) therapy. (1) Cardiologists must always attempt to treat reversible causes of cardiomyopathy prior to implanting an ICD. (2) During this period of diagnostic testing and treatment, patients are at risk for sudden cardiac death and must be protected. External LifeVest defibrillator therapy provides such protection while physicians determine whether treatment will result in an improvement in cardiac function. 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. This patient's severely depressed LVEF, ventricular ectopy and delayed gadolinium enhancement place him at high risk for sudden cardiac death during titration of anticongestive 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) 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for an automatic external defibrillator is overturned. Medical Necessity is substantiated.