ModifiedUnitedHealthcarePolicy CS255PAC

Left Atrial Appendage Closure (Occlusion) (for Pennsylvania Only)

Policy governs percutaneous endovascular and surgical left atrial appendage (LAA) closure for stroke risk reduction in patients with atrial fibrillation, applied only to Pennsylvania members and evaluated case-by-case per state exceptions.

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion) (for Pennsylvania Only)

Policy CodePolicy CS255PAC

Change TypeCoverage rationale addedcoding list updatedthoracoscopic approach not addressed

Effective DateDec 1, 2024

Next Review DateN/A

Key ActionInclude applicable procedure code(s) and required clinical documentation (diagnosis of nonvalvular AF, CHA2DS2‑VASc score, and contraindication to long‑term anticoagulation) when requesting prior authorization.

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 Applicable Codes.

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

Pennsylvania-onlyjurisdiction

≥2CHA2DS2-VASc threshold

≥18age requirement (surgical)

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.

procedure codes listed

≈7951meta-analysis N

Coverage Criteria for Left Atrial Appendage Closure

Percutaneous endovascular LAA closure (medically necessary)

Covered when ALL of the following are met:

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

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

Stroke risk: Moderate to high risk of embolic stroke as evidenced by CHA2DS2-VASc score ≥ 2CHA2DS2-VASc ≥ 2

Anticoagulation contraindication: Documented medical contraindication to long-term anticoagulation

Surgical LAA closure during other cardiac surgery (medically necessary)

Covered when ALL of the following are met:

Procedure context: Procedure performed as part of open cardiac surgery with cardiopulmonary bypass for a different indication (concomitant procedure)concomitant procedure

Age requirement: Patient is 18 years of age or olderAge ≥ 18 years

History of AF: History of atrial fibrillation

Stroke risk: CHA2DS2-VASc score > 2CHA2DS2-VASc > 2

Concomitant surgical LAA occlusion coverage criteria

Covered when ALL of the following are met (as supported by LAAOS III and society guidelines):

Trial population and guideline alignment: Patient with atrial fibrillation undergoing cardiac surgery with cardiopulmonary bypass for another indication AND has elevated stroke risk (LAAOS III enrolled patients with CHA2DS2-VASc ≥ 2)CHA2DS2-VASc >= 2

LAAOS III demonstrated reduced ischemic stroke/systemic embolism when occlusion was performed while most patients continued anticoagulation.

Procedure timing: LAA occlusion performed concomitantly during the cardiac surgery (not as a stand-alone procedure)concomitant procedure

LAAOS III findings apply primarily to concomitant surgical occlusion and not to stand-alone surgical or endovascular occlusion.

Antithrombotic management: Usual care including planned postoperative oral anticoagulation during follow-up (document intended post-op anticoagulation)

Coverage Rationale (details in other sections of policy)

Policy updated — Coverage Rationale added; thoracoscopic LAA closure not addressed in this policy.

Coverage update: Coverage Rationale section added to clarify criteria for percutaneous and concomitant surgical LAA closure

See other sections of the policy for clinical evidence, coding, and documentation requirements.

Thoracoscopic closure: Thoracoscopic (thoracoscopic/minimally invasive) closure/occlusion of the left atrial appendage is not addressed in this policy

Use of thoracoscopic techniques may lead to coverage uncertainty; providers should reference benefit plan requirements.

This policy does not address thoracoscopic closure (occlusion) of the left atrial appendage (LAA). Coverage criteria, coding, and clinical rationale specified here pertain to percutaneous endovascular LAA closure and surgical LAA closure performed concomitantly with other open cardiac surgery; thoracoscopic approaches fall outside the scope of this document and require case‑by‑case consideration per the member's benefit plan.

Results from LAAOS III apply to LAA occlusion performed concomitantly during open cardiac surgery and do not generalize to stand‑alone surgical or endovascular occlusion. In addition, thoracoscopic closure is not addressed in this policy, and the trial’s findings should not be interpreted as supporting routine use of thoracoscopic or isolated procedures outside the specific concomitant surgical context studied in LAAOS III.

For emphasis and operational clarity: thoracoscopic closure (occlusion) of the left atrial appendage is not addressed in this policy. Procedures using thoracoscopic techniques are not covered by the specific coverage criteria laid out for percutaneous or concomitant open surgical LAA occlusion.

This policy does not support routine LAA occlusion for all patients with nonvalvular atrial fibrillation. Randomized trials and meta‑analyses (for example, PROTECT AF and related analyses) do not demonstrate unequivocal prevention of embolic stroke across all high‑risk patients, and follow‑up duration and safety signals from device implantation limit broader application. Therefore, LAA occlusion is not recommended routinely and should be considered only when coverage criteria (such as documented contraindication to long‑term anticoagulation or guideline‑aligned indications) are met.

Evidence supporting the AtriClip and other epicardial clip systems is largely derived from observational series, registries, and small nonrandomized studies. These reports show favorable rates of anatomic occlusion and low device‑related events, but limitations include heterogeneous study designs, inconsistent post‑procedure anticoagulation, lack of contemporary randomized comparators, and small sample sizes. Comparative effectiveness versus pharmacologic therapy or established percutaneous devices therefore remains uncertain.

Historical policy language that explicitly labeled thoracoscopic LAA closure as “unproven and not medically necessary” was removed in the current revision. The policy now states that thoracoscopic LAA closure is not addressed, rather than reiterating a not‑medically‑necessary determination, and directs that such procedures be evaluated according to applicable benefit terms.

Applicable and Affected Codes

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 (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 CPT CodesCPTNot Covered

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

FDA product codes / informationalmixed

NGV	FDA product code for percutaneous LAA closure devices (search PMA database)
PZX	FDA product code for surgical LAA closure devices (search 510(k) database)

Removed CPT Codes (operational)CPTNot Covered

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

Affected codes (general)mixed

No codes listed

inv-16: CHA2DS2-VASc — threshold values

Percutaneous LAA closure thresholdCHA2DS2-VASc score ≥ 2

Surgical LAA closure threshold (concomitant during other cardiac surgery)CHA2DS2-VASc score > 2

Age requirement for surgical concomitant procedureAge ≥ 18 years

inv-17: Prior authorization

Follow benefit plan rulesPrior authorization and coverage determinations must follow the member's federal, state, or contractual benefit plan requirements

Use of InterQual

Provider Action Items, Prior Authorization & Documentation

Prior Authorization

Prior Authorization & Coding

Prior authorization is required per the member's benefit terms; include applicable CPT/ICD coding when submitting requests to facilitate review.

Prior authorization implied — verify and obtain authorization when required by the member's federal/state/contractual benefit plan.
Include applicable CPT codes (e.g., 33340, 33267, 33268) and relevant ICD-10 diagnosis codes on prior authorization and claim submissions.

Billing Rule

Code List Updated

The policy code list has been revised. CPT codes 33269 and 33999 were removed from the applicable codes list.

Updated applicable procedure codes: 33340, 33267, 33268 (see policy Applicable Codes).

Background and Context

Atrial fibrillation (AF) substantially increases the risk of cardioembolic ischemic stroke, with the left atrial appendage (LAA) being a common source of thrombus formation. Anticoagulation reduces stroke risk but may be contraindicated or carry unacceptable bleeding risk for some patients. For these individuals, mechanical LAA exclusion—either with percutaneous endovascular devices or surgical exclusion performed concomitantly with other cardiac surgery—can be considered as an alternative strategy to reduce stroke risk when used in accordance with FDA labeling and the coverage criteria described in this policy.

Definitions and Key Terms

inv-32: CHA2DS2-VASc score

DefinitionCHA2DS2-VASc is a point‑based risk stratification score to estimate long‑term systemic embolic (stroke) risk in patients with atrial fibrillation

Components (examples)Congestive heart failure, Hypertension, Age (65–74 = 1 point; ≥75 = 2 points), Diabetes mellitus, Stroke/TIA/thromboembolism (2 points), Vascular disease (prior MI/PAD/aortic plaque), Sex category (female)

Clinical useUsed to determine stroke risk and guide indications for anticoagulation or consideration of LAA occlusion

inv-33: Surgical LAA occlusion during cardiac surgery for another indication

DefinitionConcomitant surgical LAA occlusion/exclusion: surgical exclusion of the left atrial appendage performed during open cardiac surgery with cardiopulmonary bypass for a different primary indication

Policy Revision History

2024-12-01RevisionLatest

Coverage Rationale added; language stating that thoracoscopic closure (occlusion) of the left atrial appendage is not addressed in this policy was added; prior language calling thoracoscopic closure unproven and not medically necessary was removed; CPT codes 33269 and 33999 were removed from Applicable Codes; Description of Services, Clinical Evidence, FDA, and References sections updated; previous policy version CS255PAB archived.

Policy Summary

PayerUnitedHealthcare

PolicyLeft Atrial Appendage Closure (Occlusion) (for Pennsylvania Only)

Policy CodePolicy CS255PAC

Change TypeCoverage rationale addedcoding list updatedthoracoscopic approach not addressed

Effective DateDec 1, 2024

Next Review DateN/A

SourceLink

On This Page

Device labeling: Device is used according to FDA labeled indications, contraindications, warnings, and precautions, when applicable

Most LAAOS III participants continued OAC; benefit independent of stopping anticoagulation is uncertain.

UnitedHealthcare may use third‑party tools (e.g., InterQual) to assist in administering benefits and prior authorization decisions

Include applicable CPT codesWhen requesting prior authorization, include the applicable procedure code(s) listed by the policy (e.g., CPT 33340, 33267, 33268) as applicable

Do not submit claims using CPT 33269 or 33999 for LAA procedures under this policy.

Prior Authorization

Prior Authorization & Benefit Verification

Before performing or submitting for services, providers must verify coverage under the member's federal, state, and contractual benefit plan and follow any third-party clinical criteria that apply (for example, InterQual). In case of conflict, plan terms govern.

Verify coverage and authorization requirements with the member's specific benefit plan.
Follow any applicable third-party clinical tools or prior authorization vendor criteria used by UnitedHealthcare.

Denial Risk

Diagnosis & Risk Score

Coverage requires a documented diagnosis of nonvalvular atrial fibrillation and an appropriate stroke risk score (CHA2DS2-VASc). Lack of qualifying diagnosis or insufficient risk score may lead to denial.

Document the diagnosis of nonvalvular AF.
Provide the member's CHA2DS2-VASc score; policy references a threshold of ≥2 per coverage rationale and guideline language.
If the diagnosis is valvular AF or score threshold not met, coverage is not supported by this policy.

Note

Thoracoscopic Closure Not Addressed

Thoracoscopic (minimally invasive thoracoscopic) LAA closure is not addressed in this policy. Coverage for thoracoscopic procedures may be uncertain and should be confirmed with the member's benefit plan prior to scheduling.

Do not assume coverage for thoracoscopic LAA closure based on this policy; obtain benefit verification and prior authorization if applicable.
When thoracoscopic approach is proposed, include procedural details in the authorization request to aid coverage determination.

Documentation Required

Clinical Trial–Based Documentation Elements

For surgical LAA occlusion performed as part of cardiac surgery, include clinical-trial-aligned documentation elements supporting the indication (per LAAOS III): AF history, CHA2DS2-VASc score, operative notes confirming occlusion was performed and method used.

Document history of atrial fibrillation.
Provide CHA2DS2-VASc score and supporting clinical data.
Attach operative report indicating LAA occlusion was performed (technique, device or method, intraoperative TEE findings if applicable) and that procedure was performed during cardiac surgery with cardiopulmonary bypass.
If applicable, note whether the patient continued anticoagulation per usual care.

Step Therapy

Step Therapy / Medication Prerequisites

Percutaneous LAA occlusion eligibility requires a documented contraindication to long-term anticoagulation per policy and guideline recommendations; there is no step therapy requirement. Document attempts, contraindications, or high bleeding risk as applicable.

No step therapy or medication prerequisite applies.
Provide documentation of a medical contraindication to long-term anticoagulation (nonreversible cause) or evidence of high risk of major bleeding on OAC.
If prior anticoagulation was attempted, include details (drug, duration, reason for discontinuation) to support the contraindication.

Note

Guideline‑Aligned Sequencing

Follow guideline-aligned sequencing: percutaneous LAA occlusion is considered when anticoagulation is contraindicated or as an option in patients at high bleeding risk; surgical occlusion is reasonable when performed concomitantly during cardiac surgery for another indication.

For percutaneous LAAO: document contraindication to long-term anticoagulation or high bleeding risk consistent with guideline recommendations.
For patients undergoing cardiac surgery for another indication and who meet criteria (AF history, CHA2DS2-VASc ≥2), include surgical LAA occlusion as part of the operative plan and document technique and TEE confirmation where applicable.

Performed at the time of another cardiac surgery (not as a standalone procedure)

DocumentationOperative note should indicate that LAA occlusion was performed and the method used, consistent with evidence from LAAOS III

inv-34: Transcatheter device-based occlusion of the LAA

DefinitionPercutaneous (transcatheter) LAA closure: endovascular implantation of a device to occlude the left atrial appendage (e.g., Watchman, Amulet) via transseptal catheter techniques

Examples of devicesWatchman (Boston Scientific), Amulet (Abbott) — devices subject to FDA labeling and approved indications

Procedure elementsIncludes transseptal puncture, catheter placement, LAA angiography, device deployment, and associated radiological supervision and interpretation

inv-35: Key clinical evidence

PROTECT AFPROTECT AF: pivotal randomized trial evaluating the Watchman device for LAA closure (referenced in policy references)

LAAOS IIILAAOS III: randomized trial of concomitant surgical LAA occlusion during cardiac surgery demonstrating reduced ischemic stroke/systemic embolism among trial participants

Prasad et al.Prasad et al.: meta-analyses and large observational summaries cited regarding LAA occlusion outcomes and safety

Caliskan et al.Caliskan et al.: observational study reporting outcomes with epicardial AtriClip devices cited in policy references