A seven-year-old boy is prevented from receiving a device that could save his life after his insurance company refused to cover the cost – on the grounds that medical evidence did not support its use.
Decker Sharp of Nashville, Tennessee, was born with an atrioventricular septal defect and pulmonary stenosis — meaning he has holes in his heart and that his pulmonary valve is particularly narrow, CBS reports.
Sharp has been approved to exercise by a cardiologist – but warns he is likely to die if he suffers cardiac arrest while exercising, a risk for someone with his condition. A device called an automated external defibrillator (AED) could save his life.
The device could cost up to $3,000. The Sharp family is insured with Anthem, one of the country’s largest insurance providers, which refuses to insure the device. Anthem says existing medical evidence doesn’t support the need for an AED for someone like Sharp.
This has put the family in a quandary. While they want their child to keep exercising, they run the risk of dying if they don’t have the device handy.
Decker Sharp (pictured), 7, of Nashville, Tennessee, has a congenital heart defect that required two surgeries before he turned five
Sharp first had surgery to treat his condition when he was eight months old.
Years later, at the age of three, a mass developed in his heart, causing problems with the pressure and blood flow through his heart. He required a second open-heart surgery.
While he is now in good shape every day, his family fears the worst as his heart problems persist.
The boy’s ascending aorta—the largest blood vessel in the body—begins to narrow, putting pressure on his heart.
This could eventually lead to rupture of the vessel, an emergency situation that often results in death.
Sharp is also at risk of cardiac arrest if he exerts himself physically – which he often does when playing sports.
Sharp does sports, which his cardiologist allows. Doctors recommend that the family have an AED on hand while he exerts himself in case he suffers a potentially fatal cardiac arrest
Cardiologists recommend his parents have an AED on hand, a device that can shock the heart quickly and restart it in an emergency.
While some people are having the device surgically inserted into the heart, the Sharps are looking for a version to carry around just in case.
This makes it a lot cheaper, costing $1,000 to $3,000 for the device. Surgery could drive the price into the tens of thousands.
However, Anthem rejected the prescription, saying it was not supported by medical literature.
“The existing medical evidence does not support that AEDs offer any benefit to patients with atrial septal defects and therefore these devices are not a covered benefit under the family health plan,” the company told CBS.
Sharp’s family says they are disappointed but not surprised by the insurance company’s decision.
Sharp’s insurance company, Anthem, has refused to cover the purchase of the device, which could cost up to $3,000. They say the medical literature doesn’t support its use for his condition
“We are disappointed by Anthem’s decision, but unfortunately not surprised,” the family said in a statement.
“Our hope remains that this will initiate a conversation to establish parameters of when AED care is appropriate.
“You certainly save lives. Additionally, we wholeheartedly believe that physicians should make healthcare decisions, not insurance companies.’
Allowing insurance companies to reject doctor recommendations has become a controversial, stressful, and sometimes deadly practice.
The companies reserve the right to refuse to pay for certain medications, treatments and other expenses they deem unreasonable.
However, insurance adjusters are not usually medical experts, which creates a situation where a doctor might recommend a treatment – only to have it rejected by someone who is not an expert.
The patient can still receive the treatment, but he would have to pay for it out of his own pocket.
