CurrentExcellus Health Plan IncPolicy 7.01.92

Left Atrial Appendage Closure Devices

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This policy governs medical appropriateness and investigational status for percutaneous and surgical left atrial appendage occlusion or exclusion procedures used for stroke prevention in individuals with atrial fibrillation.

Policy Summary

PayerExcellus Health Plan Inc

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation but inability to take long-term oral anticoagulation through shared decision-making.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CHA2DS2-VASc ≥2Stroke-risk threshold used in coverage criteria

5%/yearEstimated incidence of stroke in untreated atrial fibrillation

90%Estimated proportion of left atrial thrombi occurring in the left atrial appendage

395PINNACLE FLX trial enrollment

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CurrentExcellus Health Plan IncPolicy 7.01.92

Left Atrial Appendage Closure Devices

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Policy Summary

PayerExcellus Health Plan Inc

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation but inability to take long-term oral anticoagulation through shared decision-making.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CHA2DS2-VASc ≥2Stroke-risk threshold used in coverage criteria

5%/yearEstimated incidence of stroke in untreated atrial fibrillation

90%Estimated proportion of left atrial thrombi occurring in the left atrial appendage

395PINNACLE FLX trial enrollment

Two-year ischemic stroke or systemic embolism rate in the PINNACLE FLX trial

1,878Amplatzer Amulet IDE trial enrollment

Medical Necessity and Investigational Criteria

Percutaneous LAA occlusion

Percutaneous left atrial appendage occlusion devices are medically appropriate when ALL of the following criteria are met.

Percutaneous LAA occlusion criteria

FDA approval: The device is approved by the U.S. Food and Drug Administration (FDA).FDA-approved device
Atrial fibrillation type: The individual has nonvalvular atrial fibrillation (AF).
Stroke and systemic embolism risk: The individual has increased risk of stroke and systemic embolism based on a CHA2DS2-VASc score greater than or equal to two (2).CHA2DS2-VASc ≥2
Anticoagulation recommendation: Systemic anticoagulation therapy is recommended.
Relative risk of anticoagulation: The long-term risks of systemic anticoagulation outweigh the risks of device implantation.
See the Policy Guideline section.

Surgical LAA exclusion or excision during cardiac surgery

Surgical exclusion or excision of the left atrial appendage during cardiac surgery is medically appropriate when ALL of the following criteria are met.

Surgical LAA exclusion or excision criteria

Postoperative anticoagulation: The individual is planning to continue long-term anticoagulation after surgery.
Treatment goal: The goal is to reduce the risk of stroke.
Atrial fibrillation diagnosis: The individual is diagnosed with atrial fibrillation.
Stroke risk: The individual has a CHA2DS2-VASc score greater than or equal to two (2) or equivalent stroke risk.CHA2DS2-VASc ≥2 or equivalent stroke risk

Investigational percutaneous LAA closure

Percutaneous left atrial appendage closure devices are considered investigational when the percutaneous medical-appropriateness criteria are not met.

Investigational percutaneous use: The criteria for medically appropriate percutaneous LAA occlusion are not met.

Investigational surgical LAA exclusion devices

Surgical LAA exclusion devices, including AtriClip, are considered investigational for either of the following indications in individuals with atrial fibrillation for stroke prevention.

Investigational surgical device indications

Stand-alone procedure: The surgical LAA exclusion device is used as a stand-alone procedure.
Thoracoscopic cardiac procedure: The individual is undergoing a thoracoscopic cardiac procedure.

Concomitant surgical LAA exclusion in patients with AF

ACC/AHA 2023 recommendation for concomitant surgical LAA exclusion or excision.

Concomitant surgical LAA exclusion is indicated

Required conditions: Atrial fibrillation; cardiac surgery; moderate or high stroke risk; and continued anticoagulation.CHA2DS2-VASc ≥2 or equivalent

Technical endpoint for surgical LAA exclusion

ACC/AHA 2023 technical recommendation.

Adequate surgical exclusion technique: For patients with atrial fibrillation undergoing cardiac surgery and LAA exclusion, use a surgical technique that produces no flow across the suture line and leaves an LAA stump less than 1 cm, as determined by intraoperative transesophageal echocardiography.No flow across suture line; stump <1 cm

ACC/AHA COR 1; LOE A.

Percutaneous LAAO with nonreversible contraindication to anticoagulation

ACC/AHA 2023 recommendation for percutaneous LAA occlusion.

Percutaneous LAAO is reasonable: The patient has atrial fibrillation, moderate to high stroke risk, and a contraindication to long-term oral anticoagulation due to a nonreversible cause.CHADS2 score ≥2

ACC/AHA COR 2a; LOE B-NR.

Percutaneous LAAO for high bleeding risk on anticoagulation

ACC/AHA 2023 alternative recommendation.

Percutaneous LAAO may be an alternative based on patient preference: The patient has atrial fibrillation, moderate to high stroke risk, and high risk of major bleeding on oral anticoagulation; patient preference supports pLAAO after careful consideration of procedural risk and the more extensive evidence supporting oral anticoagulation.Moderate to high stroke risk; high risk of major bleeding

ACC/AHA COR 2b; LOE B-R. This is a preference-sensitive alternative.

STS recommendations for surgical LAA obliteration

Society of Thoracic Surgeons 2023 recommendations.

Surgical LAA obliteration settings

Concomitant cardiac surgery: The patient has atrial fibrillation and is undergoing a first-time nonemergent cardiac surgery procedure, with or without concomitant surgical ablation.First-time nonemergent cardiac surgery
Recommended; COR I, LOE A.
Stand-alone surgical management: The patient has longstanding persistent atrial fibrillation, high stroke risk, and contraindication to or failure of long-term oral anticoagulation.High stroke risk; anticoagulation contraindication or failure
May be considered; COR IIb, LOE B-NR.

Percutaneous LAAO with contraindication to anticoagulation

Percutaneous LAAO is reasonable when ALL of the following clinical conditions are present.

Percutaneous LAAO clinical indication: The patient has atrial fibrillation, moderate to high stroke risk with a CHA2DS2 score of at least 2, and a contraindication to long-term oral anticoagulation due to a nonreversible cause.CHA2DS2 score ≥2

Guideline recommendation: COR 2a; LOE B-NR.

Percutaneous LAAO for high bleeding risk

Percutaneous LAAO may be reasonable as an alternative to oral anticoagulation when ALL of the following clinical considerations are present.

Alternative to oral anticoagulation: The patient has atrial fibrillation, moderate to high stroke risk, high risk of major bleeding on oral anticoagulation, and a preference for pLAAO after careful consideration of procedural risk.Moderate to high stroke risk; high risk of major bleeding

The evidence for oral anticoagulation is more extensive. Guideline recommendation: COR 2b; LOE B-R.

Concomitant surgical LAA management

Concomitant surgical LAA management is recommended in the following setting.

Concomitant surgical LAA obliteration: The patient has atrial fibrillation and is undergoing a first-time nonemergent cardiac surgery procedure, with or without concomitant surgical ablation.First-time nonemergent cardiac surgery

Recommendation: COR I; LOE A.

Stand-alone surgical LAA management

Stand-alone surgical LAA obliteration may be considered when ALL of the following are present.

Stand-alone surgical LAA obliteration: The patient has longstanding persistent atrial fibrillation, high stroke risk, and contraindication to or failure of long-term oral anticoagulation.High stroke risk

Recommendation: COR IIb; LOE B-NR.

The Amplatzer cardiac plug is FDA-approved for closure of atrial septal defects but has not received FDA approval for left atrial appendage closure. LAAO devices and related components require FDA approval before marketing and use in the United States.

CPT 33267 (open exclusion of the left atrial appendage) and CPT 33269 (thoracoscopic exclusion of the left atrial appendage) are designated experimental/investigational under this policy.

Billing and Diagnosis Codes

Covered CPT CodesCPTCovered

33268	Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any methods (e.g., excision, isolation via stapling, oversewing, ligation, plication, clip) (List separately in addition to code for primary procedure).
33340	Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation

Experimental/Investigational CPT CodesCPTExperimental

33267	Exclusion of left atrial appendage, open, any method (e.g., excision, isolation via stapling, oversewing, ligation, plication clip).
33269	Exclusion of left atrial appendage, thoracoscopic, any method (e.g., excision, isolation via stapling, oversewing, ligation, plication, clip).

HCPCS Codes — Not ApplicableHCPCS

No codes listed

ICD10 CodesICD-10

I48.0-I48.21	Atrial fibrillation (code range).
I48.91	Unspecified atrial fibrillation

CHA2DS2-VASc Threshold

CHA2DS2-VASc thresholdGreater than or equal to two (2)

Percutaneous useIncreased risk of stroke and systemic embolism based on a CHA2DS2-VASc score greater than or equal to two (2)

Surgical useA score greater than or equal to two (2) or equivalent stroke risk for surgical left atrial appendage exclusion or excision during cardiac surgery

CHA2DS2 Threshold

CHA2DS2 threshold≥2

Clinical settingAtrial fibrillation with moderate to high risk of stroke

Documentation, Billing, and Coverage Conditions

Documentation Required

Document Anticoagulation Suitability and Shared Decision-Making

Before implantation, document that the patient is suitable for short-term oral anticoagulation but unable to take long-term oral anticoagulation. This determination must be made through shared decision-making between the patient and a non-implanting physician involved in the patient’s care, such as the primary care physician or primary cardiologist.

Document the shared decision-making interaction in the medical record.
Identify the non-implanting physician participating in the decision.

Documentation Required

Document Individualized Risk-Benefit Assessment

Document an individualized, evidence-based assessment of the balance between implantation risks and benefits when considering percutaneous LAA occlusion as an alternative to systemic oral anticoagulation.

Use an evidence-based decision tool.
Take the patient’s demonstrated bleeding episodes into account.

Clinical Background

Atrial fibrillation reduces effective atrial contraction, causing blood stasis and increasing the risk of thrombus formation and thromboembolic stroke. The left atrial appendage has the lowest blood flow during atrial fibrillation and is therefore the area of greatest thrombotic risk. Stroke prevention is a central goal of atrial fibrillation treatment; systemic anticoagulation is effective but may increase bleeding risk, require monitoring, or have other limitations. Left atrial appendage closure or exclusion may be evaluated as an alternative or adjunctive approach based on stroke risk, anticoagulation considerations, and procedural risk.

Clinical Terms and Risk Scores

Atrial Fibrillation Stroke-Risk Scores

PurposeRisk-stratification scores used to calculate stroke risk in patients with atrial fibrillation

CHADS2 factorsCongestive heart failure, hypertension, age greater than 75, diabetes, and stroke, transient ischemic attack, or thromboembolism

CHA2DS2-VASc factorsCongestive heart failure, hypertension, diabetes, stroke, transient ischemic attack, or thromboembolism, plus age greater than or equal to 65, vascular disease, and gender category

Left Atrial Appendage

Anatomical locationPortion of the left atrium

Blood flow during atrial fibrillationArea with the lowest blood flow

Policy Summary

PayerExcellus Health Plan Inc

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation but inability to take long-term oral anticoagulation through shared decision-making.

SourceLink

On This Page

Associated indicationContraindication to long-term oral anticoagulation due to a nonreversible cause

Address both implantation risks and anticoagulation risks.

Denial Risk

Percutaneous Criteria Not Met

Percutaneous LAA closure is considered investigational when the applicable medical-appropriateness criteria are not satisfied.

Confirm that all required percutaneous criteria are met before proceeding.
Expect investigational treatment status when the criteria are not met.

Denial Risk

Surgical LAA Exclusion Devices Are Investigational

Surgical LAA exclusion devices, including AtriClip, are considered investigational for stroke prevention in individuals with atrial fibrillation when performed as a stand-alone procedure or during a thoracoscopic cardiac procedure.

Stand-alone surgical LAA exclusion is investigational.
Surgical LAA exclusion during a thoracoscopic cardiac procedure is investigational.
This applies to surgical LAA exclusion devices, including AtriClip.

Billing Rule

Experimental Surgical LAA Exclusion Codes

CPT 33267 and CPT 33269 are identified as experimental/investigational and may be denied or treated as experimental/investigational when billed for surgical exclusion of the left atrial appendage.

33267 (E/I): Exclusion of left atrial appendage, open, by any method, including excision, stapling, oversewing, ligation, plication, or clip.
33269 (E/I): Exclusion of left atrial appendage, thoracoscopic, by any method, including excision, stapling, oversewing, ligation, plication, or clip.
Verify benefit and policy status before submitting these codes.

Denial Risk

Use Only an FDA-Approved LAA Closure Device

Do not use the Amplatzer cardiac plug for LAA closure as an FDA-approved indication. The device is FDA-approved for closure of atrial septal defects but has not received FDA approval for LAA closure.

FDA approval is required for LAAO devices and related components before marketing and use in the United States.
The FDA-approved Amplatzer Amulet LAA occluder is distinct from the non-approved Amplatzer cardiac plug indication for LAA closure.

Note

Confirm Benefit and Program Coverage

Coverage is subject to the member’s applicable product benefit and any governing government-program requirements. Confirm those requirements in addition to applying the policy’s medical-appropriateness criteria.

Policy criteria do not supersede applicable benefit exclusions or limitations.
Check program-specific coverage requirements when applicable.

Thrombus riskArea with the highest risk of thrombosis

CHADS2

PurposeStroke-risk stratification score used in patients with atrial fibrillation

Congestive heart failureOne scoring component

Other componentsHypertension; age greater than 75; diabetes; and stroke, transient ischemic attack, or thromboembolism

CHA2DS2-VASc

PurposeStroke-risk stratification score used in patients with atrial fibrillation

Shared componentsCongestive heart failure, hypertension, diabetes, and stroke, transient ischemic attack, or thromboembolism

Additional componentsAge greater than or equal to 65, vascular disease, and gender category

HAS-BLED

PurposeBleeding-risk score for patients with atrial fibrillation treated with warfarin

Score range0 to 9

ComponentsHypertension; abnormal renal and/or liver function; stroke; bleeding; labile international normalized ratios; age older than 65; and drug and/or alcohol use

High-risk thresholdScores of 3 or greater are associated with high risk of bleeding

Left Atrial Appendage Closure or Occlusion

Procedure typesPercutaneous or surgical procedure

Anatomical targetOccludes or excludes the left atrial appendage

Clinical purposeReduces formation or systemic embolization of thrombus

Nonvalvular Atrial Fibrillation

DefinitionAtrial fibrillation occurring without associated moderate-to-severe mitral stenosis or a mechanical heart valve

Relevant populationThe cited device studies and recommendations refer primarily to this population

Treatment contextLAA closure devices are evaluated for stroke prevention in atrial fibrillation

pLAAO

AbbreviationpLAAO

Full termPercutaneous left atrial appendage occlusion

Clinical contextA percutaneous approach used for patients with atrial fibrillation and relevant stroke and anticoagulation considerations

LAAO Device

DefinitionA left atrial appendage occlusion medical device regulated by the U.S. Food and Drug Administration

Approval requirementAll LAAO devices, including related components, require FDA approval before marketing and use in the United States

FDA-approved percutaneous devices identifiedWatchman, Watchman FLX, and Amplatzer Amulet LAA occluder

Non-approved device notedThe Amplatzer cardiac plug has FDA approval for atrial septal defect closure but not for left atrial appendage closure