Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Durable Medical Equipment (DME)(including Wearable Defibrillators). 
The insurer denied a Zoll LifeVest. 
The denial was overturned.

This patient is a male, active smoker with no prior past medical history. He presented to the emergency department (ED) with worsening shortness of breath and chest tightness due to a non-ST elevation myocardial infarction (NSTEMI). Coronary angiogram showed severe multivessel coronary artery disease (CAD). The patient underwent a 3-vessel coronary artery bypass graft (CABG) (left internal mammary artery (LIMA) -left anterior descending (LAD), saphenous vein graft (SVG)-obtuse marginal (OM), saphenous vein graft (SVG) -right coronary artery (RCA)). The echocardiogram showed severely reduced, dilated cardiomyopathy with left ventricular ejection fraction (LVEF) 20%. The patient was started on evidence-based medical therapy for his newly diagnosed CAD and severe ischemic cardiomyopathy, and he was discharged home with a LifeVest (WCD) for protection against sudden cardiac death. A multigated acquisition (MUGA) scan showed improved LVEF to 40% prompting discontinuation of his WCD.
At issue is whether the proposed health treatment of Zoll LifeVest is likely to be more beneficial than any standard treatment for the patient.

The health plan's determination regarding the proposed treatment is overturned in whole.

The proposed health treatment of Zoll LifeVest was likely to be more beneficial than any standard treatment for the patient.
The LifeVest prescribed for this patient was medically appropriate, necessary, and more beneficial than any other alternative treatments. The current body of published medical literature on the use of the WCD demonstrates that this device is both safe and highly effective at terminating potentially life-threatening ventricular arrhythmias.
Finally, according to the 2017 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death, the WCD is reasonable for patients, not ineligible for implantable cardioverter defibrillator (ICD), at high risk of sudden death due to life-threatening ventricular arrhythmias with LVEF 35% or less during the 90 day period after revascularization, as in this case, while monitoring for recovery of cardiac function. (3) For these reasons, the WCD is medically appropriate, necessary, and beneficial in this case for protection against ventricular arrhythmias while allowing time for myocardial recovery after revascularization and with optimization of medical therapy prior to ICD implantation.
The patient was at high risk for sudden death due to severe life-threatening ventricular arrhythmias in the early post MI period. The current body of evidence demonstrates that the WCD is both safe and effective at terminating ventricular arrhythmias and reducing all-cause mortality in patients post MI with low LVEF. For these reasons, the WCD was a medically appropriate and necessary treatment to protect this patient from life threatening ventricular arrhythmias during the 90-day waiting period while monitoring for recovery of cardiac function.
Therefore, the proposed health treatment of Zoll LifeVest was likely to be more beneficial than any standard treatment.