Currentsierra health and lifePolicy 2025T0637G

Left Atrial Appendage Closure (Occlusion)

Clinical coverage policy for percutaneous endovascular and surgical closure (occlusion) of the left atrial appendage to reduce stroke risk in patients with atrial fibrillation, including device-specific evidence summaries and code references; applies to relevant commercial and individual exchange plans noted.

Policy Summary

Payersierra health and life

PolicyLeft Atrial Appendage Closure (Occlusion)

Policy CodePolicy 2025T0637G

Change TypeTemplate update / application expansion

Effective DateMay 1, 2025

Next Review Date

Key ActionObtain prior authorization and document nonvalvular AF, CHA2DS2-VASc score (≥2), and a documented contraindication to long-term anticoagulation when requesting percutaneous LAA closure.

SourceLink

POLICY UPDATE CHANGES

Created shared policy version to support application to Rocky Mountain Health Plans membership Application Individual Exchange.

Removed language indicating this Medical Policy does not apply to the state of Colorado.

≥2minimum stroke risk score for coverage

33267,33268,33340example procedure codes

4.8% vs 7.0%LAAOS III stroke rate

05/01/2025policy revision date

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Left Atrial Appendage Closure

Percutaneous Endovascular LAA Closure (Occlusion)

Covered when ALL of the following are met:

Percutaneous LAA closure coverage criteria: Device is used according to FDA labeled indications, contraindications, warnings, and precautions; Diagnosis of nonvalvular atrial fibrillation (AF); Moderate to high risk of embolic stroke (CHA2DS2-VASc Score >= 2); Documented medical contraindication to long-term anticoagulationCHA2DS2-VASc >= 2

Device must be FDA approved

Surgical LAA Closure (Occlusion) During Cardiac Surgery

Covered when ALL of the following are met:

Surgical LAA closure coverage criteria: Age 18 years or above; History of atrial fibrillation; CHA2DS2-VASc Score >= 2; Device is used according to FDA labeled indications, contraindications, warnings, and precautions, when applicableCHA2DS2-VASc >= 2

LAA occlusion must occur during separate cardiac surgery for a different indication

Covered clinical scenarios and guideline-based positions

Coverage-relevant clinical positions reflected in evidence and guideline statements in this section:

Surgical concomitant LAA occlusion: Patients with atrial fibrillation undergoing cardiac surgery with cardiopulmonary bypass and CHA2DS2-VASc >= 2 who receive usual care including anticoagulation — concomitant surgical LAA exclusion is indicated to reduce stroke and systemic embolism (supported by LAAOS III and guideline Class I, Level A).CHA2DS2-VASc >= 2

Applies to concomitant surgical LAA occlusion; majority of LAAOS III participants continued anticoagulation

Percutaneous LAA occlusion candidacy: Percutaneous LAA closure may be reasonable for AF patients with moderate-to-high stroke risk who have contraindications to long-term anticoagulation, or a high risk of major bleeding on oral anticoagulation — guideline recommendations vary by scenario (Class 2a/2b).moderate-to-high stroke risk

Guidelines state do not offer LAA occlusion as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated

Thoracoscopic closure (occlusion) of the left atrial appendage (LAA) is not addressed in this policy.

Guideline and policy guidance emphasize that LAA occlusion should not be offered as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated. When anticoagulation can be safely used, it remains the standard therapy and LAA occlusion is considered primarily when long‑term oral anticoagulation is not an option.

There are no explicit exclusions listed in the policy text excerpts provided; coverage determinations must reference the member‑specific benefit plan document, which governs in the event of any conflict and may impose exclusions or limits.

Available comparative evidence does not definitively demonstrate superiority of any single percutaneous LAA device. Assessments and meta‑analyses have been inconclusive, with limited high‑quality randomized data and short to moderate follow‑up; therefore, long‑term comparative superiority between devices (for example, Amplatzer Amulet versus Watchman) remains uncertain.

Procedure Codes, Scoring, and Coding Notes

Applicable procedure codesCPT

33267	Exclusion of left atrial appendage, open, any method (e.g., excision, isolation via stapling, oversewing, ligation, plication, clip).
33268	Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any method (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.

inv-09: CHA2DS2-VASc score threshold — ≥ 2

CHA2DS2-VASc score thresholdCHA2DS2-VASc ≥ 2

Purpose of thresholdDefines moderate-to-high embolic stroke risk for consideration of LAA occlusion

Applies toPercutaneous endovascular closure (requires contraindication to long-term anticoagulation) and surgical LAA closure during other cardiac surgery

Documentation requiredCHA2DS2-VASc score must be calculated and recorded in clinical documentation

Prior Authorization, Documentation, and Provider Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for procedures when procedure codes for percutaneous or open LAA exclusion/closure are submitted; inclusion of those codes in this policy implies prior authorization may be required. Verify prior authorization requirements with the member-specific benefit plan before scheduling or performing the procedure.

Affected codes (examples): CPT 33267, 33268, 33340 — check member plan for full list and authorization rules.
Prior authorization is governed by the member-specific benefit plan and any applicable federal/state mandates.

Documentation Required

Documentation Requirements

Document the clinical rationale thoroughly. For percutaneous LAA closure, include nonvalvular AF diagnosis, CHA2DS2-VASc score, documentation of moderate-to-high stroke risk, and a documented contraindication to long-term anticoagulation or intolerance to OAC. For surgical LAA exclusion performed during cardiac surgery, document age, AF history, CHA2DS2-VASc score (≥2), the indication for the concomitant surgical procedure, and the surgical technique used (with intraoperative assessment of absence of flow and stump <1 cm when applicable). Also document the specific device used and that it was used per FDA-labeled indications, contraindications, warnings, and precautions when applicable.

Clinical Background and Evidence Context

Atrial fibrillation (AF) is a common source of cardioembolic ischemic stroke, and thrombus formation frequently originates in the left atrial appendage (LAA). Anticoagulation is the standard preventive therapy to reduce stroke risk, but it carries bleeding risk; percutaneous or surgical LAA closure/occlusion are treatment options to reduce stroke risk, particularly when long‑term anticoagulation is contraindicated or not tolerated.

Key Terms and Scores

inv-23: CHA2DS2-VASc Score — point-based risk stratification schema description

Score nameCHA2DS2-VASc Score (Birmingham schema)

TypePoint-based risk stratification schema to estimate long-term systemic embolization risk in patients with atrial fibrillation

Components (examples)Congestive heart failure (1), Hypertension (1), Age ≥75 (2), Diabetes (1), Stroke/TIA (2), Vascular disease (1), Age 65–74 (1), Female sex (1)

Original referenceLip, 2010 (described as the 2009 Birmingham Schema)

inv-24: CHA2DS2-VASc — clinical stroke risk score used to stratify patients; guidelines referenced require score ≥2 for consideration

Clinical roleClinical stroke risk score used to stratify patients with atrial fibrillation for stroke prevention decisions

Policy Summary

Payersierra health and life

PolicyLeft Atrial Appendage Closure (Occlusion)

Policy CodePolicy 2025T0637G

Change TypeTemplate update / application expansion

Effective DateMay 1, 2025

Next Review Date

Key ActionObtain prior authorization and document nonvalvular AF, CHA2DS2-VASc score (≥2), and a documented contraindication to long-term anticoagulation when requesting percutaneous LAA closure.

SourceLink

On This Page

Required documentation for percutaneous LAA occlusion: diagnosis of nonvalvular AF; CHA2DS2-VASc score ≥ 2; documented medical contraindication to long-term anticoagulation; device name and evidence of FDA-labeled use.
Required documentation for surgical LAA exclusion during cardiac surgery: age ≥18; history of AF; CHA2DS2-VASc score ≥2; indication for the concomitant cardiac surgery; description of surgical technique and intraoperative TEE findings showing absence of flow and stump <1 cm when applicable.

Denial Risk

Coverage Criteria Failures — Denial Risk

Services that do not meet the policy's coverage criteria are not covered. Examples include: procedures performed without use of an FDA-approved device when required, procedures for patients without a diagnosis of nonvalvular AF, CHA2DS2-VASc score below the policy threshold when that is a coverage requirement, or absence of documentation of contraindication to long-term anticoagulation for percutaneous LAA closure.

Coverage criteria failures may result in claim denial or lack of reimbursement.
FDA approval alone is informational and does not guarantee coverage — applicable coverage criteria must be met.

Note

FDA Status — Informational

FDA approval status for LAA devices is provided for informational purposes only and is not by itself a basis for coverage. Verify current FDA approval or 510(k)/PMA status when relevant; links to FDA databases are available for device lookup.

FDA resources: PMA database (Product Code NGV) and 510(k) PMN database (Product Code PZX).
FDA approval status does not override member-specific benefit plan terms.

Note

Member-Specific Benefit Plan Governs

The member-specific benefit plan document governs coverage decisions and prevails in the event of any conflict with this policy. Check for plan exclusions, prior authorization requirements, and any applicable federal or state mandates before rendering services.

Before providing services, review the member-specific benefit plan and any applicable federal/state mandates.
In Medicare Advantage contexts, in the absence of an NCD/LCD, the MAO may establish coverage using objective evidence-based rationale.

Note

Anticoagulation First — Guideline Note

Anticoagulation is the standard of care for stroke prevention in AF. LAA occlusion (percutaneous or surgical) should not be used as a substitute for indicated anticoagulation except when anticoagulation is contraindicated or not tolerated, consistent with guideline recommendations.

Percutaneous LAA closure is reasonable for AF patients with moderate-to-high stroke risk and a contraindication to long-term anticoagulation.
Do not offer LAA occlusion as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated.

Step Therapy

Step Therapy (Not Specified)

Step therapy is not specified in this policy. If a member-specific plan imposes step therapy requirements for LAA-related services, follow the plan's criteria and prior authorization processes.

No step therapy rules are provided in this policy.
Follow any plan-specific step therapy or utilization management requirements if present.

Guideline requirement for surgical considerationGuidelines recommend surgical LAA exclusion for patients undergoing cardiac surgery with CHA2DS2-VASc ≥ 2 (Class I, Level A)

Guideline position for percutaneous closurePercutaneous LAA closure is reasonable for AF patients with moderate-to-high stroke risk who have contraindications to long-term anticoagulation (Class 2a) or may be reasonable when high bleeding risk (Class 2b)

inv-25: LAA occlusion/closure — definition: percutaneous or surgical interventions to exclude the LAA from systemic circulation

DefinitionLeft atrial appendage (LAA) occlusion/closure: percutaneous or surgical interventions to exclude the LAA from systemic circulation to reduce stroke risk in patients with atrial fibrillation

Percutaneous methodsTranscatheter endocardial implant devices (e.g., Watchman and successors) placed via transseptal access

Surgical methodsOpen surgical techniques performed during cardiac surgery (excision, oversewing, ligation, stapling, clip) to exclude the LAA

Intended effectReduce thromboembolic stroke risk by excluding LAA as a source of thrombus