7-year-old boy with congenital heart defect denied lifesaving medical device by insurance company

A Tennessee household is hoping their struggle to get a lifesaving medical device for his or her son highlights the necessity for medical doctors — and never insurance firms — to make essential well being care choices.

The boy, 7-year-old Decker Sharp, is wise, athletic, humorous and offers the perfect hugs, his mom informed CBS News. But Decker was born with congenital heart defects — particularly, an atrioventricular septal defect and pulmonary stenosis. That means his heart was crammed with holes and the pulmonary valve was too slender, in accordance with his household, who lives in Nashville.

At 8 months previous, he had his first open-heart surgical procedure to restore these defects. Then, at 3 years previous, he had one other open-heart surgical procedure as a result of a mass had developed resulting in his aorta and that was affecting the strain and blood stream to his heart.

Looking at Decker, one would not know something is mistaken, however there’s one other downside lurking. Decker’s ascending aorta is basically thinning and there is strain constructing in his heart, the household mentioned.

Decker additionally likes to play sports activities, which is one thing that runs in his household. His father, Doug Sharp, was a U.S. Olympian who received a bronze medal in bobsledding in 2002. Decker’s pediatric heart specialist is permitting the boy to play sports activities, however she informed his dad and mom that they should carry round an automatic exterior defibrillator, or AED, at his sports activities occasions. The device is used to shock somebody’s heart.

The heart specialist, Dr. English Flack, who works at Monroe Carell Jr. Children’s Hospital at Vanderbilt, believes Decker could also be in danger for sudden cardiac demise whereas exercising due to his aortic stenosis, which is the results of his congenital heart defect. She informed the household that she worries Decker’s first cardiac arrest could be a giant one — and the final because it might kill him.

Decker Sharp

But Anthem, the insurance company for Decker and his household, denied the physician’s prescription for an AED.

In an announcement to CBS News, Anthem mentioned it made the choice after rigorously reviewing the case, its medical insurance policies and the medical literature relating to use of AEDs for atrial septal defects.

“The existing medical evidence does not support that AEDs offer benefit to patients with atrial septal defects, and as a result, these devices are not a covered benefit under the family’s heath plan,” the assertion reads.

CBS News’ David Begnaud famous that if Flack had been to say that Decker must have an implantable cardioverter defibrillator (ICD) linked to his heart, which isn’t what she’s recommending at this level in his life, the insurance would cover it. But her prescription for the dad and mom to hold round an AED to save lots of their son’s life given his excessive threat of sudden cardiac arrest has been denied.

An AED isn’t used to repair a heart defect, however it’s used to save lots of somebody’s life if an individual with a defect goes into sudden cardiac arrest. That’s why an AED is required. The device, which prices between $1,000 and $3,000, can be really useful by the American Medical Association and could be present in virtually each ambulance in America.

“We are disappointed in Anthem’s decision, but unfortunately not surprised,” Decker’s household mentioned in an announcement. “Our hope remains that this will start a conversation to set parameters around when AED coverage is appropriate. They certainly save lives. Moreover, we whole heartedly believe doctors should lead healthcare decisions, not insurance companies.”

Anthem’s full assertion:

“We understand Decker’s parents’ concern given his condition. Our clinical team has carefully reviewed and re-reviewed Decker’s case, our medical policies, and the medical literature regarding use of AEDs for atrial septal defects. The existing medical evidence does not support that AEDs offer benefit to patients with atrial septal defects, and as a result, these devices are not a covered benefit under the family’s health plan.

“Anthem Blue Cross and Blue Shield’s appeals course of does afford the household further evaluate from an impartial doctor ought to they need to train that choice. This course of gives additional alternatives for brand new or further info and circumstances to be thought of within the protection resolution. Anthem’s protection insurance policies are based mostly on evidence-based drugs using medical society position statements, main peer-review medical journals and enter from doctor specialists throughout the nation.”

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