Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Cardiac arrest
Treatment: Wearable Cardioverter Defibrillator (K0606)
The insurer denied the Wearable Cardioverter Defibrillator (K0606)
The denial is upheld.

The patient is a gentleman. He had an out-of-hospital VF (ventricular fibrillatrion) arrest while shoveling snow. Bystander CPR (cardiopulmonary resuscitation) was performed, and defibrillation was performed with return of spontaneous circulation. The patient was brought to the hospital intubated, and hypothermia protocol was delivered. Upon arrival, ECG (electrocardiogram) revealed AF (atrial fibrillation) with right bundle branch block and ST (sinus tachycardia) depressions across the anterior lateral leads.

The patient's past medical history was significant for hypertension, paroxysmal atrial fibrillation and remote ablation for a SVT (supraventricular tachycardia) due to a left sided accessory pathway. The patient had complete neurologic recovery, and cardiac catheterization was performed. Findings revealed no significant obstruction in the left coronary arteries.
A distal lesion (40%) was noted in the RCA (right coronary artery), and the PDA (posterior descending artery) demonstrated collateral flow consistent with an occlusion. Recommendations were made for secondary prevention ICD (implantable cardioverter defibrillator) implantation.

A note by the physician clearly documents that the patient is undecided regarding the type of ICD (implantable cardioverter defibrillator) implantation (subcutaneous versus transvenous) and will be discharged home with an external Lifevest defibrillator. The patient ultimately was discharged and underwent subcutaneous defibrillator therapy.

No, the health plan should not cover the wearable cardioverter defibrillator.

This patient had a clear indication for secondary prevention ICD (implantable cardioverter defibrillator) implantation. This should have been performed prior to discharge from the hospital.

This patient should have received standard therapy- ICD (implantable cardioverter defibrillator) implantation at initial admission. AHA/ACC/HRS (American Heart Association/American College of Cardiology/Heart Rhythm Society) guidelines recommend ICD (implantable cardioverter defibrillator) implantation following cardiac arrest without reversible cause (Reference 1,2). Current American Heart Association Science Advisory regarding wearable LifeVest therapy recommends that external LifeVest defibrillators may be beneficial in situations where implantable defibrillators cannot be utilized or when there is a heightened risk of sudden cardiac death that is expected to resolve over time (Reference 3). In this case, the patient
had a clear indication for an implantable ICD (implantable cardioverter defibrillator) upon initial presentation. Therefore, the wearable cardioverter defibrillator was not appropriate.

No, the requested therapy (external LifeVest defibrillator) was not likely to be more beneficial than standard ICD (implantable cardioverter defibrillator) therapy (Reference 1, 2). This patient had a clear indication for an implantable cardiac defibrillator. External LifeVest is inferior to such therapy and is not indicated in this situation (Reference 1, 2).