Insurance wont cover a DCM diagnosis?

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Our tale of grain-free diets, dilated cardiomyopathy and ultrasounds all starts with pet owner Lisa Connor coming in for an appointment with Dr. Esther Stone to examine Brutus, her 150-pound Great Dane. Lisa lives alone with Brutus, but she works from home, which allows her to shower affection on her canine housemate. Her limited income hasn't stopped her from providing Brutus with a comfortable lifestyle: He sees the veterinarian on a regular basis, has pet health insurance and eats a high-quality dog food … or so she thought.

Six years ago, when Brutus came into her life, Lisa researched the best of everything for her new pet. She familiarized herself with the positive attributes of grain-free, high-quality dog food. At the time, grain-free, vegetable-laden diets were well respected, healthy and growing in popularity. Recently, Lisa has read about the newly recognized relationship between grain-free dog food and the serious heart abnormality of dilated cardiomyopathy (DCM). Once the FDA verified the link between these diets and heart disease, she decided she needed to bring Brutus into the clinic for an exam.

Diagnosing without signs

Brutus had eaten a grain-free dog food exclusively for six years. Dr Stone examines the dog and finds him to have a normal gross physical exam, but Dr. Stone explains that the cardiac condition can't be detected with a conventional physical exam. In fact, listening to the dog's heart and even taking chest radiographs may not reveal the presence of DCM. The diagnosis requires a cardiac ultrasound examination, Dr. Stone explains. That would produce definitive results, but it's costly. Lisa confidently explains that her pet health insurance should help pay for it.

However, when Dr. Stone contacts Lisa's pet insurance company on her behalf, she's told that a cardiac ultrasound won't be covered because Brutus presented with no signs of potential cardiac disease. Dr. Stone explains her patient's risk factors and that not screening a large-breed dog on a six-year diet of exclusively grain-free dog food via ultrasonography would be negligent care. The insurance company representative doesn't disagree but insists they can't provide coverage for asymptomatic patients.

Judging on pet-owner-reported signs

Lisa is understandably angry and frustrated, as she doesn't have the money for the ultrasound. Dr. Stone tells her to stop feeding the grain-free food immediately and shares with her signs to watch for that would require Brutus to get further medical assistance. Lisa takes Brutus home, writes a passionate letter to the pet insurance company and follows Dr. Stone's direction to change the dog's food.

Two weeks later, Brutus shows up again in Dr. Stone's office. Lisa tells her that Brutus has started coughing and seems to have decreased stamina. Dr. Stone examines the patient and accepts the pet owner's description of the dog's signs as credible. She orders a cardiac ultrasound, which is now covered by pet insurance. Results show some minor age-related heart enlargement but no other abnormalities. Lisa is relieved that her dog has no signs of grain-free-food–related DCM.

So, do you suspect Lisa fudged the signs? Did she manipulate her veterinarian into ordering a cardiac ultrasound by fraudulent means? Should Dr. Stone have seen the sudden onset of reported cardiac symptoms by the owner as a sham to get around the pet insurance company's first refusal to cover the ultrasound? Let us know at dvm360news@mmhgroup.com.

Dr. Rosenberg's response

It's unfortunate that grain-free-food–related DCM can only be definitively diagnosed by costly cardiac ultrasonography. Hopefully, the specific shortcomings in these diets can be corrected so the problem disappears and the insurance coverage, or lack of it, becomes moot.

That said, this is a real-time problem that must be dealt with immediately. When unique medical conditions arise, the pet owner, veterinarian and pet insurance company must work together to assist the patient. It's true that many medical conditions are declined coverage when a patient is asymptomatic and only has the potential to develop a disease. This, however, is a unique situation involving fatal consequences when not addressed.

I personally feel that pet insurance companies should cover the ultrasound procedure in these cases and make the necessary actuarial adjustments in their premiums to minimize any losses. The last thing that anybody wants is a pet owner or veterinarian feeling that they have to skirt the truth to get the care a pet needs.

Dr. Marc Rosenberg is director of the Voorhees Veterinary Center in Voorhees, New Jersey. In his private time, he enjoys playing basketball and swing dancing with his wife. Although many of the scenarios Dr. Rosenberg describes are based on real-life events, the veterinary practices, doctors and employees described are fictional.