A seven-year-old boy is being prevented from receiving a device that could save his life after his insurance company declined to cover it – saying that medical evidence did not support using it.
Decker Sharp, of Nashville, Tennessee, was born with an atrioventricular septal defect and pulmonary stenosis – which means that he has holes in his heart and that his pulmonary valve is especially narrow, reports CBS.
Sharp has been cleared by a cardiologist to play sports – but warns that if he suffers cardiac arrest while straining himself, a risk for someone with his condition, than he will likely die. A device called a automated external defibrillator (AED) could save his life, though.
The device could cost up to $3,000. The Sharp family is insured by Anthem, one of the nation’s largest insurance providers, who is refusing to cover the device. Anthem says that existing medical evidence does not support the need for an AED for someone like Sharp.
This has left the family in a bind. While they would like for their child to continue playing sports, doing opens the risk of him dying if they do not have the device on hand.
Decker Sharp (pictured), 7, of Nashville, Tennessee has a congenital heart condition that required two surgeries before he turned five
Sharp first received surgery to treat his condition when he was eight months old.
Years later, at age three, a mass developed in his heart that was causing issues with the pressure and flow of blood through his heart. He required a second open heart surgery.
While he is in good condition day-to-day now, his family fears the worst as his heart issues linger.
The boy’s ascending aorta – the largest blood vessel in the body – is starting to thin, causing pressure to build in his heart.
This could lead to the vessel eventually tearing, an emergency situation that often results in death.
Sharp is also at risk of suffering cardiac arrest when he physically strains himself – which he often does as he plays sports.
Sharp plays sports, which his cardiologist allows. Doctors recommend that the family keep an AED on hand while he exerts himself just in-case he goes into a potentially deadly cardiac arrest
Cardiologists recommend his parents to keep an AED on hand, a device that can quickly shock the heart and restart it in case of emergency.
While some people have the device surgically inserted into the heart, the Sharp’s are looking to have a version they can carry around tp use in case.
This makes is much cheaper, coming in at $1,000 to $3,000 for the device. Surgery could drive up the price into the tens-of-thousands.
Anthem denied the prescription, though, saying that it is not supported by medical literature.
‘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 company told CBS.
Sharp’s family says they are disappointed, but not surprised about the insurance company’s choice.
Sharp’s insurance, Anthem, has refused to cover purchase of the device, which could cost up to $3,000. They say medical literature does not support using it for his condition
‘We are disappointed in Anthem’s decision, but unfortunately not surprised,’ the family said in a statement.
‘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.’
Insurance companies being allowed to reject recommendations made by doctors has become a controversial, stressful, and sometimes deadly practice.
The companies reserve the right to deny coverage for certain medications, procedures and other expenses if they do not see them fit.
Insurance adjusters are not usually medical experts, though, creating a situation where a doctor could recommend treatment – only for it to be declined by someone who is not an expert.
The patient is still allowed to receive the treatment, just they would have to pay for it themselves out-of-pocket.