Heart Attack Patient Denied Device Coverage; the insurer responds

WAUKESHA, Wis. – It’s a prescribed device a doctor told a Waukesha man that could save his life. Yet his insurer denied coverage, calling the device “not medically necessary.”

After surviving a heart attack at just 47, Dan Saccomando was taking no chances. That’s why he wore the ZOLL LifeVest, a wearable defibrillator, every day.

“I’d rather have the chance to live than not,” Saccomando told Contact 6.

Saccomando was told the device would act as a failsafe until he could undergo surgery for an implantable cardioverter defibrillator (ICD) in his chest. The LifeVest is designed to deliver shock treatments when the patient’s heart begins to fail.

“He’s there for me in case something happens,” Saccomando said.

Saccomando wore the LifeVest for more than six months, between his heart attack in May and his ICD operation on December 6. He says the device was expensive, between two and three thousand dollars a month.

His insurance, Anthem Blue Cross and Blue Shield, refused to cover the LifeVest.

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He told Contact 6 in a statement: “Although Anthem Blue Cross and Blue Shield cover portable automatic defibrillators in certain situations, medical research and current standards of care do not support the use of these devices after a heart attack, and they are not covered under Anthem’s medical policy in cases like this.”

The statement says the insurer sympathizes with Saccomando and understands Saccomando’s “point of view,” but says its policy “is consistent with those of the entire industry,” including Medicare.

Dan Sorajja, a cardiac electrophysiologist at the Mayo Clinic, wants to see more health insurance providers endorse ZOLL LifeVest coverage.

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Sorajja supports wearing the device after a heart attack. That’s when he says the patient is at higher risk for sudden cardiac arrest and is waiting for his heart pumping function to improve enough to have surgery.

“The device is quite commonly prescribed,” Sorajja said. “This LifeVest is kind of a bridge…to get you to that point where you can get a permanent defibrillator.”

Sorajja says he disagrees with a number of insurance denials. He says research shows the device can reduce a patient’s risk of death.

“I think the scale of the problem is very big in this country,” Sorajja said. “I think [the LifeVest] certainly fills a very important niche in our patient care.”

Anthem sent Contact 6 its policy and a list of resources to support its decision that the device is not medically necessary in Saccomando’s case. It includes citations from a number of medical studies.

Medicare also sent Contact 6 its similar policy on portable defibrillators.

Consumers have a few options when a health insurer decides that a medical device or procedure is not necessary. Their first step should be to contact their doctor’s office for advice. Their office may send the insurer more documentation or resubmit them under a different medical code.

The member has the right to appeal to the insurer. If that doesn’t work, they can try filing a complaint with the Office of the Wisconsin Insurance Commissioner.

Dalip Singh is a cardiologist at Milwaukee VA Medical Center. He is not Saccomando’s doctor nor does he intervene in the insurance debate, but he prescribes the LifeVest and supports its use after a heart attack when pumping function is poor.

“Most people get better. If they don’t get better, that’s when they get a [defibrillator]. It acts like a bridge when we don’t know if it’s going to get better or not,” Singh said.

Singh says the device is mostly useful for people whose permanent defibrillators have been removed due to infection. Over the past three years, at least two patients have received shock treatment with the LifeVest.

“Which means if they weren’t wearing the defibrillator, they probably would have died,” Singh told Contact 6.

Saccomando is disheartened by the denial, but plans to file a final external appeal with Anthem. He plans to live a long life and spend part of it fighting for what he believes in.

“It’s about everyone else who’s afraid to stand up and fight,” Saccomando said.

Contact 6 contacted ZOLL, but was told that “ZOLL employees are unable to give interviews or comment.” A public relations manager referred Contact 6 to its website instead.

The FDA first approved the ZOLL LifeVest in 2002.

Currently, the ZOLL LifeVest is the only wearable defibrillator on the market, although other devices are in development.