Percutaneous Left Atrial Appendage Closure - Medical Policy
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This policy governs prior authorization and medical-necessity review for percutaneous left atrial appendage closure in Health New England Commercial, Medicare, and Medicaid lines of business. Coverage review uses adopted InterQual criteria, with separate Medicare criteria based on the applicable LAAC National Coverage Determination and clinical-trial pathway.
Medicare review criteria updated.
InterQual criteria adopted for Commercial and Medicaid review.
Coverage Criteria
Commercial and Medicaid Criteria
For Commercial and Medicaid members, coverage is based on the applicable adopted InterQual criteria.
ALL of the following
- Health New England has adopted InterQual criteria for percutaneous left atrial appendage closure: CP: Procedures, Left Atrial Appendage Closure, Left Atrial Appendage Closure, Percutaneous.
- There are no MassHealth guidelines for percutaneous left atrial appendage closure.
Medicare Criteria
For Medicare members, coverage is based on the applicable Medicare InterQual criteria and National Coverage Determination requirements.
ONE of the following Medicare criteria pathways
- Medicare: Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) (CED).
- Medicare: Procedures, Percutaneous Left Atrial Appendage Closure (LAAC) NCD, Left Atrial Appendage Closure (LAAC) Clinical Trial.
Members Under 18
Requests for members under 18 years of age are reviewed individually.
ALL of the following
- The member is under 18 years of age.
The request will be reviewed on a case-by-case basis.
Eligible Device Types
Coverage is limited to the following eligible device types.
ONE of the following devices
- Watchman device.
- Amplatzer Amulet device.
- Lariat suture delivery device.
Percutaneous left atrial appendage closure using any device other than the Watchman device, Amplatzer Amulet, or Lariat suture delivery device is considered experimental/investigational.
Left atrial appendage closure for conditions that do not meet the applicable InterQual or Medicare criteria is considered not medically necessary.
Coding
| 33340 | Percutaneous transcatheter closure of 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 |
Provider Actions
Obtain prior authorization and submit clinical evidence
Prior authorization is required for review under this medical policy. The treating physician or primary care provider must submit clinical evidence demonstrating that the patient meets the applicable medical-necessity criteria.
Submit supporting clinical evidence
The treating physician or primary care provider must submit clinical evidence showing that the patient meets the applicable criteria for the procedure. Without supporting documentation and information, Health New England cannot properly review the prior-authorization request.
Requests failing criteria may be denied
Requests that do not meet the applicable InterQual or Medicare criteria are considered not medically necessary.
Use an eligible device
Percutaneous left atrial appendage closure using any device other than the Watchman device, Amplatzer Amulet, or Lariat suture delivery device is considered experimental or investigational.
Background
Atrial fibrillation increases the risk of stroke, and the left atrial appendage is a potential source of thromboemboli. Percutaneous left atrial appendage closure provides a non-pharmacologic alternative for selected patients with atrial fibrillation by closing the appendage to reduce thromboembolic risk.
Risk Score Definitions
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