Ischemic Cardiomyopathy: Disputing LifeVest Coverage Denial

The records have been reviewed. The member is an adult male with a birth date of 02/09/1959. He has a diagnosis of ischemic cardiomyopathy. His treating provider, Maria Costanzo, MD, recommended the Zoll LifeVest (wearable cardioverter defibrillator) for the following dates of service 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 (totaling 4 units).

The carrier has denied coverage for the Zoll LifeVest as experimental and/or investigational and not medically necessary. A letter from the carrier to the member, dated 07/05/2016, which states in part:
“As you can see from the wearable cardioverter-defibrillator coverage policy cited above, a LifeVest is only allowed when it has been determined that an ICD is needed, the criteria

The use of a WCD is not always appropriate. Given the clinical features of this case and aforementioned review of information, the benefit of a WCD would be insufficient to warrant coverage. Therefore, coverage of a WCD not recommended for this member.

Therefore, the carrier’s decision to deny coverage for the Zoll LifeVest (K0606-wearable cardioverter defibrillator) for the dates of 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 as experimental and/or investigational was appropriate.

The Zoll LifeVest (K0606-wearable cardioverter defibrillator) for the dates of 09/02/2015, 10/02/2015, 12/02/2015, 01/02/2016-02/02/2016 was not medically necessary for the treatment of this member’s condition.

The expected benefit of the recommended or requested health care service or treatment is not more likely to be beneficial to the member than any available standard health care service or treatment.

The adverse risks of the recommended or requested health care service or treatment are not substantially increased over those of available standard health care services or