Zoll Life Vest denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for Zoll LifeVest. Primary prevention implantable cardioverter-defibrillator (ICD) is recommended to prevent sudden cardiac arrest (SCA) and death due to ventricular tachycardia/fibrillation (VT/VF) in patients with heart failure and left ventricular ejection fraction (LVEF) of less than 36% only after a minimum of three months of guideline-directed medical therapy (GDMT). Several studies have examined whether wearable cardioverter-defibrillator (WCD) offers protection against SCA/death during these three months where GDMT is prescribed and titrated.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Zoll LifeVest. The researchers’ guidelines note that patients with recent myocardial infarction, newly diagnosed nonischemic cardiomyopathy, recent revascularization, myocarditis, and secondary cardiomyopathy are at increased risk of sudden cardiac arrest. Patients who may benefit from automatic emergency cardioversion-defibrillation but do not meet indications for implantable cardioverter-defibrillator (ICD) implantation at the time of presentation include those who are at perceived increased risk of sudden cardiac death due to severe left ventricle dysfunction but for whom there may be optimism for clinical improvement, and those who have a clear indication for ICD but who have a contraindication to immediate placement.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a Zoll LifeVest for treatment of the enrollee who had a recent episode of tachycardia. Findings: 2/3 of the physician reviewers found that based on the records provided, the patient has been diagnosed with a newly recognized nonischemic cardiomyopathy, a left ventricular ejection fraction of about 30 to 35% and sustained wide complex tachycardia of uncertain origin in the absence of documented syncope. In this circumstance, since the origin of the tachycardia is not clearly ventricular and may be supraventricular, further evaluation with an electrophysiology study is most appropriate to define the tachycardia prior to committing to a defibrillator (wearable of implantable).

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest durable medical equipment for treatment of the enrollee’s dilated cardiomyopathy. Findings: 2/3 of the physician reviewers found that based on the records provided the patient is a 65-year-old male who presented with heart failure and coronary ischemia treated with coronary bypass and left ventricular aneurysmectomy with a post-operative left ventricular ejection fraction of 25-30%. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Zoll Life Vest, then check the rights and deadlines that apply to your plan.