Diagnosis: Endocarditis
Treatment LifeVest
The insurer denied the LifeVest.
The determination is overturned in part.


This is a patient with immune thrombocytopenic purpura (ITP), status/post splenectomy (s/p) , recurrent endocarditis, s/p tricuspid valve debridement and repair, strep G aortic valve endocarditis, treated for 6 weeks with ceftriaxone. She is s/p aortic and tricuspid valve replacements. She had complete heart block, with a pacemaker, then a Cardiac Resynchronization Therapy (CRT) device placed. She was admitted for right ventricular (RV) failure and severe aortic insufficiency with aortic valve endocarditis. She had a redo aortic and tricuspid valve replacement. Postoperatively, she had complete heart block, and the placement of a pacemaker. There was an issue with a lead malfunction, but the lead was not replaced. She was discharged to rehabilitation. A transesophageal echocardiogram (ECHO) showed severe biventricular dysfunction, left ventricular (LV) ejection fraction (EF) 20%, mild mitral and tricuspid regurgitation. The aortic valve gradient was elevated, but the prosthetic valve appeared to open normally. There was a possible thrombus on the prosthetic tricuspid valve. She was discharged with a LifeVest. She was re-admitted with polymorphic ventricular tachycardia (VT), requiring shocks from the LifeVest. She underwent an upgrade of her pacemaker to a biventricular implantable cardioverter defibrillator (ICD). Medications were adjusted, and she was started on a milrinone infusion which was continued at discharge. She was referred for a transplant evaluation.
At issue is the medical necessity of the LifeVest
Question(s):
The wearable defibrillator was medically necessary in part during the waiting period for an implantable defibrillator. She has a dilated cardiomyopathy due to valvular heart disease, with aortic and tricuspid valve replacements and EF 20%. She met criteria for an ICD, but at the time of discharge had a temporary condition preventing ICD implant - recent surgeries and treatment for endocarditis. There are no reasonable, medically appropriate alternatives. The LifeVest is appropriate, and in this case, successfully resuscitated the patient from ventricular tachycardia.