When Will Health Insurance Companies Start Denying Coverage for Implantable Defibrillators? They’ve Already Started.

Dear Readers, The Affordable Care Act prohibits health insurance plans from putting “lifetime” dollar limits on covered services. It will also prohibit insurance companies from denying coverage of patients with preexisting medical conditions. These changes have been touted as a victory for patients with chronic diseases. However, it looks like the health insurance companies are one step ahead. A colleague recently informed me that his patient was denied coverage by her health insurance provider for a defibrillator generator replacement. This seemed impossible. Unfortunately it is true. His patient with congestive heart failure underwent implantation of a defibrillator for primary prevention of sudden death in the late 1990s as part of the SCD-HeFT Trial. Her insurance covered the device implantation, even though it was investigational at the time. A few years after device implantation, she received a lifesaving shock for an episode of syncopal ventricular fibrillation. In 2000, the patient switched employers and health insurance. She enrolled at the time in her new employer’s health insurance plan. In 2004, when her device reached the elective replacement indicator, the patient underwent an upgrade of her device to a cardiac resynchronization therapy defibrillator (CRT-D) at the time of her generator replacement. Her insurance company fully covered the procedure. She had a noticeable improvement in her heart failure symptoms. In 2008, the patient received a letter and a booklet from her insurance company. The letter instructed her to review the certificate and booklet carefully “as it may be different than any other insurance you have had previously”. Last month her second device reached battery depletion. She contacted her insurance company. On September 22nd, she received an “Adverse Determination” letter from the Benefits Department. Unfortunately, deep within the fine print of the 53-page booklet that she had received two years earlier, under a section entitled “Durable Medical Equipment/Prosthetics”, the following statement can be found: “excluding … ventricular assist devices, … , implantable internal defibrillators.” She was told she had 180 days to appeal. The letter contained several other wonderful phrases usually reserved for a subpoena, such as “good faith” and “without prejudice”. So now what? Let her battery deplete entirely while she goes through the appeal process? Not only does her plan no longer cover a proven lifesaving therapy, a therapy that has been covered by Medicare for many years, it does not even cover replacement of a previously implanted device — a device that in this patient has clearly lead to a longer and better life. Did they really think she would find in the 53-page booklet’s fine print, under a section with an obtuse heading, that they would not cover her defibrillator replacement when the time came?

• How is this scenario any different than insurance companies denying coverage for preexisting conditions? Are patients with a preexisting condition helped if insurance companies are forced to accept them, but can then simply deny coverage of therapies that are medically necessary for their disease? • How is this any different than forcing a patient to withdraw medical care? What if this patient were pacemaker dependent and would die instantly if the device were not replaced? What if she already had a left ventricular assist device that needed to be replaced? What was the worry over government death panels when health insurance companies already have death panels?

No average American worker can afford to pay for a CRT-D generator change. Without the safety net of health insurance coverage, this patient had to turn to her health care team as her safety net. Fortunately, her physician was able to get the device company to provide the device free of charge, and the hospital to write off her bill as part of an indigent patient program. The Affordable Care Act may help some patients, but when a health insurance company can arbitrarily select which medically necessary, lifesaving procedures they will cover, and notify a patient of these changes in a 53-page booklet with fine print, it is clear the insurance companies are still in charge. Sincerely, Bradley P. Knight, MD, FACC, FHRS Editor-in-Chief, EP Lab Digest