ModifiedUnitedHealthcarePolicy CSZ55NM.B

Left Atrial Appendage Closure (Occlusion) (for New Mexico Only)

This policy governs coverage for percutaneous endovascular and surgical closure (occlusion) of the left atrial appendage for members in New Mexico, including device-specific evidence considerations and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion) (for New Mexico Only)

Policy CodePolicy CSZ55NM.B

Change TypeRemoved language on thoracoscopic approachesCPT code removals

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting nonvalvular AF, CHADS2‑VASc ≥2, device per FDA labeling, and contraindication to long-term anticoagulation when applicable.

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 due to insufficient evidence of safety and/or efficacy.

Removed CPT codes 33269 and 33999 from the list of applicable codes.

Updated Description of Services; Clinical Evidence, FDA, and References sections to reflect the most current information.

2CPT codes removed

CHADS2‑VASc ≥2Stroke risk threshold

33267/33268/33340

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Procedural codes listed

HR 0.67Key RCT outcome (LAAOS III)

~4 yrsMean follow-up (LAAOS III)

Coverage Criteria for Left Atrial Appendage (LAA) Closure

Percutaneous endovascular LAA closure (medically necessary)

Percutaneous endovascular LAA closure is proven and medically necessary when ALL of the following are met:

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

From Coverage Rationale; device use per FDA labeling required

Device and use: Device is used according to FDA labeled indications, contraindications, warnings, and precautions

FDA-approved device required per policy

Stroke risk: Moderate to high risk of embolic stroke as indicated by CHADS2-VASc score >= 2CHADS2-VASc >= 2

Specified CHADS2-VASc threshold for coverage

Anticoagulation contraindication: Documented medical contraindication to long-term anticoagulation

Required documentation to support contraindication to OAC

Surgical LAA closure during cardiac surgery (medically necessary)

Surgical LAA closure as part of cardiac surgery with cardiopulmonary bypass for a different indication is proven and medically necessary when ALL of the following are met:

Age: Patient is aged 18 years or older

Adult patients only per coverage rationale

Atrial fibrillation history: History of atrial fibrillation

Required clinical diagnosis

Stroke risk: CHADS2-VASc score >= 2CHADS2-VASc >= 2

Matches enrollment criteria and trial evidence (LAAOS III)

Device/procedure use:

Concomitant surgical LAA occlusion — covered criteria

Covered when ALL of the following are met (evidence-focused summary from randomized trials and meta-analyses):

Concomitant procedure: LAA occlusion performed at the time of cardiac surgery with cardiopulmonary bypass for a different primary indication

LAAOS III and pooled analyses support benefit for concomitant s-LAAO; findings apply primarily to concomitant procedures

Patient risk: Patient has atrial fibrillation with CHADS2-VASc score >= 2CHADS2-VASc >= 2

LAAOS III enrolled patients with CHADS2-VASc >= 2 (mean ~4.2)

Usual care continuation: Patient will receive usual care including appropriate anticoagulation as indicated postoperatively

In LAAOS III most participants continued oral anticoagulation; trial did not compare LAAO versus OAC alone

Guideline-based considerations

Considered or guideline-recommended scenarios and practical considerations:

Percutaneous LAA closure when OAC contraindicated: Percutaneous LAA closure may be reasonable for patients with AF at moderate-to-high stroke risk who have contraindications to long-term anticoagulation

AHA/ACC/HRS, ESC/EACTS, and NICE provide conditional support for LAA occlusion when anticoagulation is contraindicated or not tolerated

Surgical LAA exclusion during cardiac surgery: Surgical LAA exclusion is indicated for individuals with AF undergoing cardiac surgery with CHADS2-VASc >= 2, performed in addition to continued anticoagulation to reduce stroke/systemic embolismCHADS2-VASc >=2

AHA/ACC: Class 1, Level A recommendation for concomitant exclusion with continued anticoagulation; STS also recommends obliteration with first-time non-emergent cardiac surgery

Technique considerations: When surgical LAA exclusion is performed, use a technique that results in absence of flow across the suture line and a residual stump < 1 cm as verified intraoperatively

Thoracoscopic closure (occlusion) of the left atrial appendage (LAA) is not addressed in this policy. The coverage criteria and procedural guidance in this document apply to percutaneous endovascular LAA closure and to surgical LAA closure performed concomitantly during cardiac surgery with cardiopulmonary bypass, as specified elsewhere in the policy.

Findings from the randomized LAAOS III trial support surgical LAA occlusion performed as a concomitant procedure during cardiac surgery and should not be generalized to stand-alone surgical or endovascular LAA occlusion. Guideline statements (AHA/ACC/HRS, NICE, ESC/STSs) similarly caution that LAA occlusion should not be used as an alternative to anticoagulation except when anticoagulation is contraindicated or not tolerated.

Operational note: policy language has been updated to clarify that thoracoscopic LAA closure is outside the scope of this policy. This replaces prior wording that characterized thoracoscopic approaches as unproven or not medically necessary; current policy simply does not address thoracoscopic LAA closure.

Coverage conditionality reminder: this section does not make a standalone coverage determination for every LAA closure approach. Coverage for LAA closure is conditional on meeting the specific criteria defined elsewhere in the policy (for example, device FDA status, diagnosis of nonvalvular AF, CHADS2‑VASc ≥ 2, documented contraindication to long‑term anticoagulation for percutaneous closure, or surgical criteria when performed concomitantly). Benefit terms and contract-specific rules also govern final coverage decisions.

Anticoagulation equivalence caution: the evidence and guideline guidance do not support treating LAA occlusion as equivalent to long‑term oral anticoagulation for patients who can tolerate anticoagulants. LAA occlusion is a consideration primarily when anticoagulation is contraindicated or not tolerated, and trials such as LAAOS III compared concomitant surgical occlusion plus usual care rather than LAA occlusion alone versus anticoagulation.

Applicable Procedure and Product Codes

Applicable procedure codesCPT

33267	Oversewing, ligation, plication, clip (LAA surgical closure)
33268	Exclusion of left atrial appendage, open, performed at time of other sternotomy or thoracotomy procedure(s), any method (List separately)
33340	Percutaneous transcatheter closure of the left atrial appendage with endocardial implant; includes fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, and radiological supervision and interpretation

Device identification/product codes (informational)mixed

NGV / PZX (Product codes mentioned)	Product codes referenced for searching FDA PMA (NGV) and 510(k) (PZX) databases; product names listed for devices (Amplatzer Amulet; AtriClip; Pendulet? Penditure; Watchman).
Amplatzer Amulet	Device name (Abbott)
AtriClip	Device name (AtriCure)
Penditure	Device name (Medtronic/Syntheon)
Watchman	Device name (Boston Scientific)

Removed CPT CodesCPTNot Covered

33269	CPT code 33269 (removed)
33999	CPT code 33999 (removed)

CHADS2-VASc score (policy threshold)

Policy stroke-risk thresholdCHADS2-VASc score >= 2

Applies toPatients considered for percutaneous endovascular LAA closure or concomitant surgical LAA occlusion

Role in coverage determinationRequired as part of prior authorization and documentation to meet medical necessity

CHADS2‑VASc (trial threshold)

Trial enrollment thresholdLAAOS III enrolled adults with AF and CHADS2‑VASc >= 2

Trial contextUsed to select participants undergoing cardiac surgery with CPB for another indication

Provider Requirements, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required

Prior authorization is required for percutaneous endovascular LAA closure when requested for coverage. Submit documentation that supports the indication (nonvalvular atrial fibrillation), the patient’s CHADS2‑VASc score, evidence of a documented contraindication to long‑term anticoagulation when that is the basis for coverage, and that the proposed device will be used according to FDA‑labeled indications, contraindications, warnings, and precautions. Prior authorization requests should also indicate whether the occlusion is being performed concomitantly with cardiac surgery and include relevant operative notes.

Prior authorization required when percutaneous LAA closure is requested for coverage.
Documentation must include: diagnosis of nonvalvular AF; CHADS2‑VASc score; rationale/records documenting contraindication to long‑term OAC when applicable; device name and intended use per FDA labeling; operative plan if concomitant with cardiac surgery.

Documentation Required

Device Approval and Coding Verification

Providers must verify and document the FDA marketing status (PMA or 510(k) as applicable) and the exact product name of the device proposed for use. Use the FDA PMA database (Product Code NGV) for percutaneous devices and the FDA 510(k) database (Product Code PZX) for surgical devices to confirm approval/clearance. Inclusion of the device product name in the prior authorization submission expedites review.

Background and Clinical Context

Background: Atrial fibrillation (AF) is a common cause of cardioembolic ischemic stroke, with many emboli originating from thrombus in the left atrial appendage (LAA). Anticoagulation reduces stroke risk but increases bleeding risk; therefore, surgical or percutaneous LAA exclusion may be used in selected patients to reduce stroke risk. Clinical trials and guideline statements inform that percutaneous LAA closure with an FDA‑approved device may be medically necessary for patients with nonvalvular AF who have a CHADS2‑VASc score of ≥ 2 and a documented contraindication to long‑term anticoagulation, and that surgical LAA occlusion performed concomitantly during cardiac surgery for another indication can reduce stroke risk when trial criteria are met.

Definitions and Trial Thresholds

CHADS2-VASc Score

DefinitionA risk stratification score (Birmingham schema) used to estimate long‑term systemic embolization (stroke) risk in patients with atrial fibrillation

Origin/referenceDescribed as the 2009 Birmingham schema (Lip, 2010)

Scoring componentsIncludes points for congestive heart failure, hypertension, age, diabetes, prior stroke/TIA/thromboembolism, vascular disease, and sex category

Concomitant surgical LAA occlusion

DefinitionOcclusion or exclusion of the left atrial appendage performed at the time of cardiac surgery with cardiopulmonary bypass for a different primary indication (e.g., CABG or valve surgery)

Coverage contextConsidered medically necessary when performed concomitantly during cardiac surgery in patients age ≥18 with AF and CHADS2‑VASc ≥2

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion) (for New Mexico Only)

Policy CodePolicy CSZ55NM.B

Change TypeRemoved language on thoracoscopic approachesCPT code removals

Effective Date

Next Review Date

Key ActionObtain prior authorization documenting nonvalvular AF, CHADS2‑VASc ≥2, device per FDA labeling, and contraindication to long-term anticoagulation when applicable.

SourceLink

On This Page

Device or surgical technique used according to FDA labeled indications, contraindications, warnings, and precautions, when applicable

Policy requires adherence to device labeling when applicable

residual stump < 1 cm

AHA/ACC guideline technical recommendation (intraoperative TEE verification)

Mean score reportedMean CHADS2‑VASc ~4.2 in LAAOS III participants

Verify device FDA status (PMA vs 510(k)) prior to submission.
Include device product name (e.g., Watchman, Amplatzer Amulet, AtriCure, etc.) in the request.

Billing Rule

Code List and Prior Authorization

Do not use CPT codes 33269 or 33999 for prior authorization or billing for LAA closure — these CPT codes have been removed from the policy. Providers should reference the applicable CPT codes retained in the policy (for example, 33340 and the listed surgical exclusion codes) and include the code(s) being requested in the authorization submission.

CPT codes 33269 and 33999 removed — do not use for prior authorization.
Reference and request authorization for applicable retained CPT codes (e.g., 33340; surgical codes 33267, 33268) as appropriate.

Note

Provider Actions — None Specified

No additional provider actions (step therapy or other operational requirements) are specified elsewhere in this section of the policy.

Documentation Required

Required Clinical Documentation

Required clinical documentation to support a prior authorization decision includes: history and documentation of atrial fibrillation, calculation and source for the CHADS2‑VASc score, anticoagulation history including reasons for contraindication or bleeding risk if coverage is based on inability to tolerate long‑term OAC, and operative notes if LAA occlusion is to be performed concomitantly with another cardiac surgery. Imaging or intraoperative TEE findings that demonstrate successful exclusion (when relevant) should be provided.

AF diagnosis and clinical history.
CHADS2‑VASc score with supporting data.
Documentation of contraindication to long‑term anticoagulation or high bleeding risk, when applicable.
Statement whether occlusion is concomitant with cardiac surgery and relevant operative notes/imaging.

Note

Benefit Terms Govern

Benefit determinations based on this Medical Policy must be made in the context of applicable federal, state, or contractual benefit plan terms. If there is any conflict between this policy and the member’s governing benefit documents or law, the federal, state, or contractual requirements govern and take precedence.

Reference the member’s plan benefit terms, federal/state laws, and contractual requirements when submitting prior authorization requests.
In the event of conflict, governing benefit terms supersede this policy.

Documentation Required

Anticoagulation Considerations

Anticoagulation considerations: continuing anticoagulation when indicated should be documented. For surgical LAA exclusion performed during cardiac surgery, note that guideline recommendations support continuing anticoagulation postoperatively when indicated; for percutaneous LAA closure, document prior anticoagulation attempts, bleeding complications, or high bleeding risk if the request is grounded on inability to tolerate long‑term OAC.

Document whether the member remains on anticoagulation or has a documented contraindication.
For percutaneous closure requests based on bleeding risk, include prior OAC history and bleeding event documentation.
For surgical concomitant LAA exclusion, note guideline nuance that benefit without continued anticoagulation is uncertain — document intended postoperative anticoagulation plan.

Evidence baseSupported by randomized evidence from LAAOS III showing reduced ischemic stroke/systemic embolism when performed concomitantly

CHADS2‑VASc score threshold in trials

Trial threshold (LAAOS III)CHADS2‑VASc >= 2

Trial populationAdults with atrial fibrillation scheduled for cardiac surgery with CPB

Implication for practicePolicy aligns coverage to the trial threshold for concomitant surgical occlusion decisions

LAA occlusion/closure

General definitionProcedures, surgical or percutaneous, intended to exclude the left atrial appendage from the circulation to reduce stroke risk in atrial fibrillation

IncludesSurgical oversewing, ligation, plication, clip, open exclusion during other cardiac surgery, and percutaneous transcatheter endocardial implant procedures

PurposePerformed to reduce ischemic stroke or systemic embolism risk in patients with AF