ModifiedUnitedHealthcarePolicy CS255.C

Left Atrial Appendage Closure (Occlusion)

This policy governs coverage and medical necessity criteria for percutaneous endovascular and surgical closure (occlusion) of the left atrial appendage for members of the payer; it describes indications, required risk status, and device/usage constraints.

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion)

Policy CodePolicy CS255.C

Change TypeModified — content, coding, and applicability updates

Effective DateDec 1, 2024

Next Review Date

Key ActionObtain prior authorization and document nonvalvular AF, CHA2DS2-VASc ≥ 2, and a documented contraindication to long-term anticoagulation.

SourceLink

POLICY UPDATE CHANGES

Added language to indicate thoracoscopic closure (occlusion) of left atrial appendage (LAA) is not addressed in this policy.

Removed language indicating thoracoscopic closure (occlusion) of the LAA as a stand-alone procedure or as an adjunct to thoracoscopic atrial fibrillation ablation is unproven and not medically necessary.

Removed CPT codes 33269 and 33999 from the Applicable Codes section.

Updated sections including Description of Services, Clinical Evidence, FDA, and References.

Added state-specific applicability notes removing Idaho and Kansas from the policy; and removed Mississippi-specific content.

CHA2DS2-VASc ≥ 2minimum stroke risk score required for coverage

≈95–98%device implant success

≈70–79%

stroke reduction vs predicted

~4,770LAAOS III participants

HR 0.67LAAOS III ischemic stroke HR

Coverage and Medical Necessity Criteria

Percutaneous endovascular LAA closure — coverage criteria

Covered when ALL of the following are met:

Percutaneous LAA closure criteria: Device is used according to FDA labeled indications, contraindications, warnings, and precautions

From Coverage Rationale for percutaneous endovascular closure.

Percutaneous LAA closure criteria: Diagnosis of nonvalvular atrial fibrillation (AF)

From Coverage Rationale for percutaneous endovascular closure.

Percutaneous LAA closure criteria: Documented medical contraindication to long-term anticoagulation

Procedure intended for patients who cannot receive long-term OAC.

Surgical LAA closure at time of other cardiac surgery — coverage criteria

Covered when ALL of the following are met:

Surgical LAA closure criteria: History of atrial fibrillation

Requirement that patient have AF.

Surgical LAA closure criteria: Device is used according to FDA labeled indications, contraindications, warnings, and precautions, when applicable

Device use per FDA labeling when applicable; surgical closure must be part of cardiac surgery for another indication with cardiopulmonary bypass.

Concomitant Surgical LAA Occlusion (supported by LAAOS III)

Evidence indicates benefit for LAA occlusion performed concomitantly with cardiac surgery in patients with AF;

Concomitant LAA occlusion criteria: Patient has atrial fibrillation AND is scheduled to undergo cardiac surgery with cardiopulmonary bypass for another indication AND the planned procedure includes surgical occlusion/exclusion of the LAA at the time of surgeryCHA2DS2-VASc >= 2 in LAAOS III population

LAAOS III enrolled adults with AF, mean CHA2DS2-VASc ~4.2; most continued OAC postoperatively and occlusion reduced ischemic stroke/systemic embolism (HR 0.67).

Percutaneous LAA Closure (device-specific evidence caveats)

Device-based percutaneous LAA closure is supported in select patients, but evidence quality and comparative data vary by device;

Percutaneous/device considerations: Use of percutaneous LAA occlusion devices (e.g., Watchman, Amplatzer Amulet, others) may be considered for patients with AF who have contraindications to long-term anticoagulation or intolerance to anticoagulation; comparative evidence between devices and versus OAC is heterogeneous and in some cases low quality.

ECRI and guideline statements note limited or inconclusive comparative evidence for some devices (Amplatzer Amulet evidence inconclusive); registries and meta-analyses provide observational data.

Device-specific caveat - Amplatzer Amulet: Evidence for the Amplatzer Amulet is inconclusive due to lack of high-quality randomized trials; observational data show high technical success but comparative effectiveness versus other devices and long-term outcomes remain uncertain.

ECRI Clinical Evidence Assessment and meta-analysis findings cited.

Guideline alignment: Guidelines (ESC, NICE) support considering LAA occlusion when anticoagulation is contraindicated or not tolerated and advise against offering LAA occlusion as an alternative to anticoagulation when anticoagulation is tolerated.

This policy does not address thoracoscopic closure (occlusion) of the left atrial appendage (LAA). Surgical LAA closure recommendations and coverage criteria in this policy refer to LAA exclusion performed as part of open cardiac surgery with cardiopulmonary bypass for another indication; thoracoscopic techniques are outside the scope of the policy.

This Medical Policy does not apply in certain states that maintain separate, state‑specific LAA closure policies. Refer to the listed state policies (for example, Idaho and Kansas) rather than this national policy when treating members in those jurisdictions.

The principal randomized evidence from LAAOS III supports surgical LAA occlusion performed concomitantly with cardiac surgery using cardiopulmonary bypass. The trial enrolled patients with AF who continued usual care including anticoagulation, and its results do not directly establish benefit for stand‑alone surgical or percutaneous LAA occlusion. Clinicians and reviewers should therefore apply LAAOS III findings primarily to concomitant procedures and require device‑ and context‑specific evidence for stand‑alone interventions.

Editorial note: language regarding thoracoscopic LAA closure has been clarified in the current policy. The policy explicitly states that thoracoscopic closure is not addressed, and prior language classifying thoracoscopic approaches as unproven or not medically necessary has been removed pending further evidence.

The procedure and diagnosis codes listed in this policy are provided for reference only. Listing a code does not imply that the service represented by the code is covered or medically necessary; coverage determinations are governed by the member's benefit contract, applicable federal/state requirements, and other legal terms.

Consistent with external guidance (NICE), LAA occlusion should not be offered as a substitute for anticoagulation when anticoagulation is tolerated and not contraindicated. Consider LAA occlusion only if anticoagulation is contraindicated or not tolerated, and document discussion of risks and benefits.

Revision note: prior policy wording that described thoracoscopic LAA closure as a stand‑alone procedure or as an adjunct to thoracoscopic AF ablation as unproven and not medically necessary has been removed. The current policy no longer makes that assertion.

Procedure and Billing Codes

Applicable procedure CPT 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.

Removed Applicable CPT CodesCPTNot Covered

33269	CPT code 33269 (removed from Applicable Codes)
33999	CPT code 33999 (removed from Applicable Codes)

CHA2DS2-VASc Score threshold — coverage requirement

Minimum CHA2DS2-VASc scoreCHA2DS2-VASc ≥ 2

Applies toPercutaneous endovascular LAA closure and surgical LAA closure performed as part of cardiac surgery when other criteria met

Purpose of thresholdDefines moderate-to-high embolic stroke risk required for coverage

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required

Prior authorization is required for percutaneous endovascular LAA occlusion and for surgical LAA occlusion performed concomitantly with cardiac surgery when coverage is being requested under this policy. Confirm prior authorization requirements with the member's benefit plan before scheduling the procedure.

Example relevant CPTs: 33340 (percutaneous transcatheter closure of the LAA). Surgical CPTs that may be used for occlusion/exclusion include 33267, 33268.
Listing of procedure codes in this policy is for reference and does not guarantee coverage; benefit contract terms govern coverage and reimbursement.

Documentation Required

Documentation Required for Concomitant Surgical LAA Occlusion

Provide the minimum clinical documentation to support medical necessity when requesting authorization for concomitant surgical LAA occlusion during cardiac surgery: clear history of atrial fibrillation, patient age ≥18 years, documented CHA2DS2‑VASc score ≥2, description of the planned cardiac surgery and how LAA occlusion will be performed, and device use consistent with FDA labeled indications (when applicable). Include documentation of anticoagulation strategy and whether long‑term OAC is planned or contraindicated.

Clinical Background and Context

Background: Atrial fibrillation is a frequent cause of cardioembolic ischemic stroke, and thrombus formation in the left atrial appendage (LAA) is a common source of emboli in AF. Anticoagulation is the standard preventive strategy, but when long‑term anticoagulation is contraindicated or not tolerated, mechanical exclusion of the LAA — either percutaneously with an FDA‑cleared device or surgically at the time of other cardiac surgery — may reduce stroke risk. The LAAOS III randomized trial demonstrated that concomitant surgical LAA occlusion in patients with AF (mean CHA2DS2‑VASc ~4.2) who largely continued anticoagulation reduced ischemic stroke or systemic embolism (hazard ratio ~0.67) over a mean follow‑up of 3.8 years.

Terms and Device Definitions

CHA2DS2-VASc Score — definition and components

DefinitionRisk stratification score (Birmingham Schema) estimating thromboembolic risk in patients with atrial fibrillation

Components / point assignmentCongestive heart failure = 1; Hypertension = 1; Age ≥75 = 2; Diabetes mellitus = 1; Prior stroke/TIA/thromboembolism = 2; Vascular disease (prior MI, PAD, or aortic plaque) = 1; Age 65–74 = 1; Female sex = 1

ScaleScore range 0–9; higher scores indicate greater stroke risk

Concomitant surgical LAA occlusion — definition (policy context)

DefinitionOcclusion of the left atrial appendage performed during cardiac surgery for another indication (with cardiopulmonary bypass)

Evidence context

Policy Updates and Change Log

2025-07-01revisionLatest

Template update — removed content/language pertaining to the state of Mississippi.

2025-06-01revision

Application update — added language that this medical policy does not apply to the states of Idaho and Kansas; refer to state-specific policy versions.

2024-12-01material_change

Coverage rationale update — added that thoracoscopic closure of the left atrial appendage is not addressed in this policy; removed prior language stating thoracoscopic closure as unproven/not medically necessary and removed CPT codes 33269 and 33999 from Applicable Codes.

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion)

Policy CodePolicy CS255.C

Change TypeModified — content, coding, and applicability updates

Effective DateDec 1, 2024

Next Review Date

Key ActionObtain prior authorization and document nonvalvular AF, CHA2DS2-VASc ≥ 2, and a documented contraindication to long-term anticoagulation.

SourceLink

On This Page

Policy aligns device use with guideline recommendations.

If anticoagulation is continued postoperatively (as in LAAOS III), document anticoagulation plan and rationale.
If anticoagulation is to be discontinued because of contraindication, include objective evidence of contraindication (e.g., prior intracranial hemorrhage) and supporting clinical notes.

Prior Authorization

Prior Authorization: Percutaneous LAA Occlusion — Required Clinical Elements

When requesting prior authorization for standalone percutaneous LAA occlusion, document: diagnosis of nonvalvular atrial fibrillation, CHA2DS2‑VASc score ≥2, and a documented medical contraindication to long‑term anticoagulation (or intolerance to anticoagulation).

NICE and ESC guidance note LAA occlusion is appropriate when anticoagulation is contraindicated or not tolerated; do not substitute LAA occlusion for anticoagulation unless contraindicated.
If prior therapy with anticoagulation was attempted and failed or was not tolerated, include records describing adverse events or reasons for discontinuation.

Step Therapy

Step Therapy Note

Step therapy is not applicable to this procedural policy. Coverage for LAA occlusion is contingent on meeting procedural criteria (including contraindication to long‑term anticoagulation when applicable), not on prior trials of step therapy medications.

Document contraindications to long‑term OAC where applicable; do not rely on step‑therapy pathways to justify procedural coverage.

Note

Evidence Applicability and Limitations

Clinical evidence such as LAAOS III supports concomitant surgical LAA occlusion in patients with AF undergoing cardiac surgery, but applicability is limited: LAAOS III findings primarily apply to concomitant surgical occlusion and do not establish equivalence to standalone surgical or percutaneous occlusion. Consider these evidence limitations when making coverage determinations.

LAAOS III does not compare LAA occlusion with OAC alone; many participants continued anticoagulation postoperatively.
Document whether the planned procedure is concomitant surgical occlusion (LAAOS‑type context) or a standalone endovascular/surgical procedure, as evidence applicability differs.

Note

Benefit Contract Alignment and Verification

In all cases, verify the member's federal, state, and contractual benefit terms prior to applying this policy. UnitedHealthcare standard policy language does not supersede plan‑specific coverage mandates; contractual requirements govern the final coverage decision.

If plan or state/federal law requires coverage contrary to this policy, follow those requirements.
Prior authorization or medical necessity determinations should reference the member's specific benefit documents and any applicable mandates.

Billing Rule

Coding Inclusion Is Not a Coverage Guarantee

Coding lists in this policy are provided for reference only. Inclusion of a code does not imply the service is covered, guarantee reimbursement, or represent an exhaustive or mandatory billing list. Confirm appropriate coding and reimbursement with payer-specific guidance and the member's benefit contract.

Examples of referenced codes: CPT 33340, CPT 33267, CPT 33268.
Use the applicable code(s) that accurately describe the performed procedure and append modifiers as required by payer rules.

Note

Anticoagulation First Unless Contraindicated

Operational guidance: prefer anticoagulation as first‑line stroke prevention for eligible patients. LAA occlusion is indicated only when long‑term anticoagulation is contraindicated, not tolerated, or when surgical concomitant occlusion is being performed per guideline and trial contexts.

Document attempts with anticoagulation or reasons anticoagulation is contraindicated.
NICE guidance: do not offer LAA occlusion as an alternative to anticoagulation unless anticoagulation is contraindicated or not tolerated.

Prior Authorization

Provider Pre‑Authorization Action Items

Provider action checklist prior to submitting an authorization request: confirm benefit plan prior authorization requirements, gather the minimum clinical documentation outlined above, document anticoagulation history or contraindication, include intended device/instrumentation and adherence to FDA labeling when applicable, and note whether the procedure is concomitant with cardiac surgery.

Attach operative plan or surgeon/cardiologist notes describing the planned method of LAA occlusion (device, epicardial clip, oversew, stapling, etc.).
Include CHA2DS2‑VASc calculation and supporting clinical notes; include imaging or prior procedure reports if relevant.
Verify and document any state/federal mandate or contractual terms that may affect coverage.

Studied in LAAOS III: adults with AF undergoing cardiac surgery for another indication, most continued anticoagulation; occlusion reduced ischemic stroke/systemic embolism (HR 0.67)

Documentation noteFor concomitant procedures, document AF history, CHA2DS2-VASc score, and that occlusion is performed during planned cardiac surgery

Amplatzer Amulet — device definition and evidence context

DeviceAmplatzer Amulet (Abbott) — percutaneous left atrial appendage occluder

Evidence summaryECRI assessment: evidence inconclusive vs OAC and Watchman due to lack of high-quality studies; suggests high technical success and reduced major bleeding up to 2 years

Research needLarge randomized trials with >2-year follow-up comparing Amulet to medical therapy and other devices are needed

AtriClip — epicardial clip device and usage

DeviceAtriClip (AtriCure) — epicardial surgical clip system for LAA exclusion

UsageUsed during open cardiac surgery to exclude the LAA; reported series show high rates of successful exclusion and low device-related complications

EvidenceSystematic reviews and registries (e.g., Toale et al., institutional series n=291) report favorable occlusion rates and low stroke incidence but are limited by nonrandomized designs

LAA closure/occlusion — procedural definition and approaches

DefinitionProcedures (percutaneous device-based or surgical) intended to exclude the left atrial appendage from the systemic circulation to reduce thromboembolic stroke risk in atrial fibrillation

ApproachesPercutaneous transcatheter endocardial implants (e.g., Watchman, Amplatzer Amulet) or surgical methods including open exclusion, ligation, stapling, oversewing, or epicardial clips (e.g., AtriClip)

Coverage contextPercutaneous closure covered when FDA‑approved device used, nonvalvular AF present, CHA2DS2‑VASc ≥2, and documented contraindication to long‑term anticoagulation; surgical closure covered when performed concomitantly with cardiac surgery and criteria met