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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Health Plan LAA Closure Coverage Update…
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    CurrentProvidence Health PlanPolicy 74

    Left Atrial Appendage Devices Closure

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    Medicare medical policy governing coverage and medical necessity criteria for percutaneous and non-percutaneous left atrial appendage closure procedures and devices for members of Providence Health Plan (Medicare). Affects clinicians requesting authorization or billing for LAA closure procedures and related devices.

    Policy Summary
    PayerProvidence Health Plan
    PolicyLeft Atrial Appendage Devices Closure
    Policy CodePolicy 74
    Change TypeAnnual review — no material changes
    Effective DateJun 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateMay 1, 2027
    Key ActionObtain prior authorization and provide complete clinical documentation when submitting requests for percutaneous or non‑percutaneous LAA closure procedures, including accurate device-to-procedure coding.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Policy 74Medicare medical policy identifier
    CPT 33340Referenced procedure code
    33267-33269Surgical procedure codes
    2026-06-01

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Effective date

    Coverage Criteria for LAA Closure

    Coverage by procedure type

    Coverage stance depends on device type and existing Medicare determinations:

    Percutaneous LAAC under Medicare NCD: Percutaneous left atrial appendage closure is addressed by Medicare NCD 20.34 and may be covered under Coverage with Evidence Development (CED) when CMS conditions (registry/clinical trial participation) are met.see NCD 20.34 and linked registries

    Providers should refer to the NCD and associated registries for participating sites and trial requirements.

    Non-percutaneous (surgical) LAA procedures: There is no Medicare NCD for non-percutaneous LAA; Company criteria are applied and some surgical LAA services (CPT 33267-33269) are considered not medically necessary for Medicare per Company policy.N/A

    In absence of Medicare coverage criteria, Company uses evidence-based internal criteria as allowed under CFR § 422.101(b)(6).

    Device indications and contraindications (partial)

    Device-specific indications and contraindications (partial):

    AtriClip indication: AtriClip LAA Exclusion System is indicated for occlusion of the left atrial appendage under direct visualization in conjunction with other open cardiac surgical procedures.

    Direct visualization requires the surgeon to see the heart directly without assistance from cameras, endoscopes, or other viewing technology.

    AtriClip limitations: Safety and effectiveness of AtriClip for atrial rhythm control management, alone or with ablative treatment, have not been established; AtriClip placement that allows blood flow into the LAA may not result in complete exclusion and/or electrical isolation.
    Amplatzer Amulet contraindications: Amplatzer Amulet is contraindicated in the presence of intracardiac thrombus, active endocarditis or other infections producing bacteremia, or when placement would interfere with other structures.

    For Medicare members, non‑percutaneous (open or thoracoscopic) left atrial appendage (LAA) procedures are considered not medically necessary under the Company Medicare medical policy. The policy explicitly lists surgical LAA procedure codes (CPT 33267, 33268, 33269) as services that are not medically necessary for Medicare and therefore are excluded from coverage; Company criteria are applied when Medicare coverage criteria are not fully established.

    All unlisted procedure codes are reviewed for medical necessity and coding accuracy at the claim level. Per the policy, if an unlisted code is submitted for non‑covered services addressed in this policy it will be denied as not covered. For unlisted codes submitted for potentially covered services, prior authorization is recommended to avoid post‑service denial.

    The policy names specific surgical LAA procedure codes and states they are not medically necessary for Medicare. Non‑percutaneous surgical LAA procedures (CPT 33267, 33268, 33269) are considered not medically necessary for Medicare under this Company policy and are therefore excluded from coverage unless otherwise determined by applicable Medicare guidance.

    When billing device HCPCS C‑codes, there must be a clear device‑to‑procedure association. The policy gives the example that when CPT 33340 is reported the appropriate device code is HCPCS C1760; billing HCPCS C2628 with CPT 33340 is not accurate and the C‑code will deny as not medically necessary. Providers should ensure accurate device‑to‑procedure coding to avoid denial.

    Coding and Procedure Codes

    Percutaneous LAAC (referenced)CPT
    33340Percutaneous Left Atrial Appendage Closure (LAAC) — referenced in product and benefit application
    Non-percutaneous (surgical) LAA proceduresCPT
    33267Excision, left atrial appendage; open
    33268Excision, left atrial appendage; thoracoscopic
    33269Other LAA surgical procedure
    CPT/HCPCS codes referencedmixed
    33340Percutaneous 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.
    33267Exclusion of left atrial appendage, open, any method (eg, excision, isolation via stapling, oversewing, ligation, plication, clip).
    33268Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (List separately in addition to code for primary procedure).
    C1760Closure device, vascular (implantable/insertable).
    C2628Closure device, vascular (implantable/insertable) Catheter, occlusion.

    Provider Actions, Prior Authorization, and Billing Instructions

    Prior Authorization

    Prior authorization recommended for LAA closure procedures

    Percutaneous LAAC (CPT 33340) and surgical LAA procedures (CPTs 33267–33269) are subject to Company Medicare review; prior authorization is recommended when Medicare coverage is not clearly established so Company criteria can be applied for medical necessity determinations.

    • Applies to CPT 33340, 33267, 33268, 33269.
    • Company criteria used when Medicare coverage criteria are not fully established (§ 422.101(b)(6)).
    Prior Authorization

    Prior authorization for unlisted or potentially covered device codes

    Submit a prior authorization when billing unlisted device or potentially covered device HCPCS/CPT codes to avoid post-service denial; ensure coding is accurate and documentation supports medical necessity.

    • All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level; prior authorization is recommended for unlisted codes submitted for potentially covered services.

    Background and Rationale

    Atrial fibrillation (AF) increases the risk of stroke, and the left atrial appendage (LAA) is a common source of thromboemboli. Anticoagulation is the established therapy to reduce stroke risk in patients with AF; percutaneous left atrial appendage closure (LAAC) has been studied as a non‑pharmacologic alternative. Because Medicare has an NCD and Coverage with Evidence Development (CED) for percutaneous LAAC, those procedures are addressed separately; in contrast, no Medicare NCD exists for non‑percutaneous surgical LAA approaches, so Company criteria apply for those services.

    Definitions and Device Terms

    Percutaneous LAAC
    DefinitionPercutaneous left atrial appendage closure (LAAC): minimally invasive transcatheter closure of the left atrial appendage as described under CPT 33340, performed via endocardial implant techniques and referenced in Medicare NCD 20.34 with Coverage with Evidence Development (CED) conditions.
    Medicare referenceMedicare NCD 20.34 allows coverage of percutaneous LAAC under Coverage with Evidence Development (CED) when CMS conditions (registry/clinical trial participation) are met.
    CodingProcedure commonly reported with CPT 33340 (percutaneous transcatheter closure of the left atrial appendage).
    Non‑percutaneous (surgical) LAA occlusion
    DefinitionNon-percutaneous (surgical) LAA occlusion: open or thoracoscopic placement of a clip device (e.g., AtriClip LAA Exclusion System) at the base of the left atrial appendage to permanently occlude it from the left atrium.

    Policy Revision History

    Policy Summary
    PayerProvidence Health Plan
    PolicyLeft Atrial Appendage Devices Closure
    Policy CodePolicy 74
    Change TypeAnnual review — no material changes
    Effective DateJun 1, 2026
    Last ReviewJun 1, 2026
    Next Review DateMay 1, 2027
    Key ActionObtain prior authorization and provide complete clinical documentation when submitting requests for percutaneous or non‑percutaneous LAA closure procedures, including accurate device-to-procedure coding.
    SourceLink
    On This Page
    Coverage Criteria for LAA ClosureCoding and Procedure CodesProvider Actions, Prior Authorization, and Billing InstructionsBackground and RationaleDefinitions and Device TermsPolicy Revision History
  1. Follow CMS claims processing guidance referenced in policy when preparing prior authorization requests.
    2. Note

    Anticoagulation is established therapy; LAAC is a non‑pharmacologic alternative

    Anticoagulation is the established pharmacologic therapy to prevent stroke in atrial fibrillation; left atrial appendage closure (LAAC) is described as a non‑pharmacologic alternative studied for patients who seek an alternative to long‑term anticoagulation.

    • Policy acknowledges anticoagulation as proven stroke prevention in AF and notes percutaneous LAAC has been studied as a non‑pharmacologic alternative.
    Documentation Required

    Document diagnoses, history, recommendations and clinical rationale for medical necessity review

    Provide complete clinical documentation to support medical necessity: diagnoses, member medical history, physician recommendations, clinical notes, and any rationale for device selection; these materials may be reviewed by a plan medical director as part of Medicare medical necessity determinations.

    • Documentation should demonstrate why the requested procedure/device is reasonable and necessary for the individual member.
    • Include physician recommendations and relevant clinical notes to support the request.
    Billing Rule

    Follow CMS billing guidance; unlisted codes are reviewed for medical necessity

    Follow CMS billing guidance (CMS Pub 100‑04 Transmittal 3515 and Medicare Claims Processing Manual Chapter 32 §69.6) and Company coding notes; unlisted codes will be reviewed for medical necessity and may be denied if submitted for non‑covered services.

    • Refer to Transmittal 3515 and Chapter 32 §69.6 for billing and clinical trial routine cost rules.
    • All unlisted codes are reviewed at claim level; submit prior authorization for potentially covered unlisted codes to avoid post‑service denial.
    Denial Risk

    Non‑percutaneous (open or thoracoscopic) LAA procedures are not medically necessary for Medicare

    Non‑percutaneous (open or thoracoscopic) LAA procedures (CPT 33267, 33268, 33269) are considered not medically necessary for Medicare per Company policy and are at risk for denial.

    • These surgical LAA CPTs are listed as not medically necessary for Medicare within the policy.
    • In absence of a Medicare NCD for non‑percutaneous LAAC, Company criteria apply and these services are excluded.
    Documentation Required

    Require clear device‑to‑procedure association when reporting device HCPCS with device‑intensive procedures

    When billing a device HCPCS code alongside a device‑intensive procedure code, include clear device‑to‑procedure association in the claim; mismatched combinations (for example, billing HCPCS C2628 with CPT 33340) will deny as not medically necessary.

    • Appropriate device for CPT 33340 is HCPCS C1760; C2628 reported with CPT 33340 is inaccurate and will deny.
    • Only hospital outpatient departments report C‑codes; ensure the correct C‑code and linkage are present on the claim.
    FDA status
    AtriClip LAA Exclusion Systems have been approved by the FDA for occlusion of the LAA when placed under direct visualization and in conjunction with other open cardiac surgical procedures.
    Procedure contextIncludes procedures performed by sternotomy (full or partial) and thoracotomy (single or multiple).
    Direct visualization (definition)
    DefinitionDirect visualization: surgeon is able to see the heart directly without assistance from a camera, endoscope, or any other viewing technology; required for AtriClip placement during open procedures.
    Included approachesDirect visualization includes procedures performed by sternotomy (full or partial) and thoracotomy (single or multiple).
    RelevanceRequired condition for FDA-approved use of AtriClip in conjunction with other open cardiac surgical procedures.
    Amplatzer Amulet — key contraindications
    Contraindication — intracardiac thrombusAmplatzer Amulet is contraindicated in the presence of intracardiac thrombus.
    Contraindication — active infectionContraindicated with active endocarditis or other infections producing bacteremia.
    Contraindication — interferenceContraindicated when placement of the device would interfere with other cardiac structures.