CurrentUnivera HealthcarePolicy 7.01.92

Left Atrial Appendage Closure Devices

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This policy governs medical necessity for percutaneous left atrial appendage occlusion devices and surgical left atrial appendage exclusion or excision in individuals with atrial fibrillation. It also identifies circumstances in which percutaneous or surgical LAA closure devices are considered investigational.

Policy Summary

PayerUnivera Healthcare

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Last ReviewSep 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation and inability to take long-term oral anticoagulation in the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CHA2DS2-VASc ≥2Stroke-risk threshold for medically appropriate LAA closure

5 criteriaRequired percutaneous LAA occlusion criteria

4 criteriaRequired surgical LAA exclusion criteria

InvestigationalPercutaneous devices when criteria are not met

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CurrentUnivera HealthcarePolicy 7.01.92

Left Atrial Appendage Closure Devices

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Policy Summary

PayerUnivera Healthcare

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Last ReviewSep 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation and inability to take long-term oral anticoagulation in the medical record.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CHA2DS2-VASc ≥2Stroke-risk threshold for medically appropriate LAA closure

5 criteriaRequired percutaneous LAA occlusion criteria

4 criteriaRequired surgical LAA exclusion criteria

InvestigationalPercutaneous devices when criteria are not met

InvestigationalSurgical LAA exclusion devices in specified settings

Medical Necessity and Investigational Criteria

Percutaneous LAA occlusion

Percutaneous left atrial appendage occlusion devices are medically appropriate when ALL of the following criteria are met.

Percutaneous LAA occlusion medical appropriateness

FDA approval: The device is approved by the U.S. Food and Drug Administration.FDA approved
Atrial fibrillation type: The individual has nonvalvular atrial fibrillation.
Stroke and systemic embolism risk: The individual has increased risk of stroke and systemic embolism based on a CHA2DS2-VASc score greater than or equal to two.CHA2DS2-VASc ≥2
Anticoagulation recommendation: Systemic anticoagulation therapy is recommended.
Relative risk of anticoagulation: The long-term risks of systemic anticoagulation outweigh the risks of device implantation.
See policy guideline requirements for individualized risk-benefit assessment.

Surgical LAA exclusion or excision

Surgical exclusion or excision of the LAA during cardiac surgery is medically appropriate when ALL of the following criteria are met.

Surgical LAA exclusion or excision during cardiac surgery

Postoperative anticoagulation: The individual is planning to continue long-term anticoagulation after surgery.
Treatment goal: The goal is to reduce the risk of stroke.
Atrial fibrillation diagnosis: The individual is diagnosed with atrial fibrillation.
Stroke risk: The individual has a CHA2DS2-VASc score greater than or equal to two or equivalent stroke risk.CHA2DS2-VASc ≥2 or equivalent stroke risk

Percutaneous devices considered investigational

Percutaneous left atrial appendage closure devices are considered investigational when the percutaneous medical-appropriateness criteria are not met.

Percutaneous device investigational status: The device is a percutaneous left atrial appendage closure device and one or more required medical-appropriateness criteria are not met.

Surgical LAA exclusion devices considered investigational

Surgical LAA exclusion devices, including the AtriClip device, are considered investigational for stroke prevention in individuals with atrial fibrillation for EITHER indication.

Investigational surgical LAA exclusion device indications

Stand-alone procedure: The surgical LAA exclusion device is used as a stand-alone procedure.
Thoracoscopic cardiac procedure: The individual is undergoing a thoracoscopic cardiac procedure.

Concomitant Surgical LAA Exclusion/Excision

ACC/AHA guideline recommendations for concomitant surgical LAA exclusion or excision in patients with atrial fibrillation undergoing cardiac surgery.

Surgical LAA exclusion indicated: The patient has atrial fibrillation, is undergoing cardiac surgery, has a CHA2DS2-VASc score of at least 2 or equivalent stroke risk, and receives surgical LAA exclusion in addition to continued anticoagulation to reduce stroke and systemic embolism risk.CHA2DS2-VASc ≥2

Class 1 recommendation; Level of Evidence A.

Adequate surgical closure technique: For a patient with atrial fibrillation undergoing cardiac surgery and LAA exclusion, use a surgical technique that results in absence of flow across the suture line and a residual stump less than 1 cm as determined by intraoperative transesophageal echocardiography.Residual stump <1 cm; no flow across suture line

Class 1 recommendation; Level of Evidence A.

Surgical exclusion without continued anticoagulation:

Percutaneous LAA Occlusion

ACC/AHA guideline recommendation for percutaneous LAA occlusion.

Percutaneous LAA occlusion for anticoagulation contraindication: The patient has atrial fibrillation, a moderate to high risk of stroke, and a contraindication to long-term oral anticoagulation due to a nonreversible cause; percutaneous LAA occlusion is reasonable.CHA2DS2 score ≥2

Class 2a recommendation; Level of Evidence B-NR.

Concomitant surgical LAA exclusion

Surgical LAA exclusion during cardiac surgery is indicated when the following conditions are met.

Concomitant surgical LAA exclusion: The patient has atrial fibrillation and is undergoing cardiac surgery; has a CHA2DS2-VASc score of at least 2 or equivalent stroke risk; and surgical LAA exclusion is performed in addition to continued anticoagulation.CHA2DS2-VASc ≥2 or equivalent stroke risk

The benefit of surgical LAA exclusion in the absence of continued anticoagulation is uncertain.

Surgical LAA exclusion technical standard

The surgical technique should meet all of the following technical conditions.

Surgical closure result: The surgical technique results in absence of flow across the suture line and a residual LAA stump of less than 1 cm, determined by intraoperative transesophageal echocardiography.Stump <1 cm and no flow across the suture line

Applies to patients with atrial fibrillation undergoing cardiac surgery with LAA exclusion.

Percutaneous LAAO for contraindication to anticoagulation

Percutaneous LAAO is reasonable when all of the following clinical circumstances are present.

Percutaneous LAAO with anticoagulation contraindication: The patient has atrial fibrillation, moderate to high stroke risk, and a nonreversible contraindication to long-term oral anticoagulation.CHA2DS2 score ≥2

Percutaneous LAAO is reasonable in this circumstance. Class 2a recommendation; Level of Evidence B-NR.

Percutaneous LAAO as an alternative for bleeding risk

Percutaneous LAAO may be considered as an alternative to oral anticoagulation when all of the following are present.

Percutaneous LAAO for high bleeding risk: The patient has atrial fibrillation, moderate to high stroke risk, and a high risk of major bleeding on oral anticoagulation; patient preference supports LAAO after careful consideration of procedural risk and the more extensive evidence base for oral anticoagulation.Moderate to high stroke risk

This is described as potentially reasonable rather than routinely preferred. Class 2b recommendation; Level of Evidence B-R.

Surgical LAA management settings

Surgical LAA management recommendations also include the following settings.

Concomitant surgery: LAA obliteration is performed during a first-time nonemergent cardiac surgery procedure in a patient with atrial fibrillation.
Recommended to reduce morbidity from thromboembolic complications; Class I recommendation, Level of Evidence A.
Stand-alone surgery: Isolated surgical LAA obliteration is considered for a patient with longstanding persistent atrial fibrillation, high stroke risk, and contraindication to or failure of long-term oral anticoagulation.High stroke risk
May be considered; Class IIb recommendation, Level of Evidence B-NR.

Surgical LAA exclusion devices, including the AtriClip device, are considered investigational for stroke prevention in individuals with atrial fibrillation when used as a stand-alone procedure or during a thoracoscopic cardiac procedure.

The Amplatzer cardiac plug is FDA-approved for closure of atrial septal defects but has not received FDA approval for left atrial appendage closure. FDA-approved percutaneous LAA closure devices listed in the policy include Watchman, Watchman FLX, and Amplatzer Amulet.

Coding and Clinical Thresholds

CPT Codes — Experimental/InvestigationalCPTExperimental

33267

Exclusion of left atrial appendage, open, any method (e.g., excision, isolation via stapling, oversewing, ligation, plication clip).

CPT CodesCPT

33268

Exclusion of left atrial appendage, open, performed at the time of other sternotomy or thoracotomy procedure(s), any methods (e.g., excision, isolation via stapling, oversewing, ligation, plication, clip) (List separately in addition to code for primary procedure).

CPT Codes — Experimental/InvestigationalCPTExperimental

33269

Exclusion of left atrial appendage, thoracoscopic, any method (e.g., excision, isolation via stapling, oversewing, ligation, plication, clip).

CPT CodesCPT

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.

HCPCS Codes — Not ApplicableHCPCS

No codes listed

ICD10 CodesICD-10

I48.0-I48.21	Atrial fibrillation (code range).
I48.91	Unspecified atrial fibrillation.

CHA2DS2-VASc Score

ThresholdCHA2DS2-VASc score greater than or equal to 2

Clinical significanceIndicates increased risk of stroke and systemic embolism

Policy useUsed for percutaneous LAA occlusion and surgical LAA exclusion or excision criteria

Stroke-Risk Thresholds

Surgical LAA exclusionCHA2DS2-VASc score ≥2 or equivalent stroke risk during cardiac surgery

Percutaneous LAA occlusion

Documentation and Denial Risks

Documentation Required

Document Anticoagulation Suitability

Document that the patient is suitable for short-term oral anticoagulation but unable to take long-term oral anticoagulation. This determination must be recorded in the medical record.

Documentation Required

Document Individualized Risk-Benefit Assessment

Document an individualized, evidence-based assessment of the risks and benefits of percutaneous left atrial appendage occlusion as an alternative to systemic oral anticoagulation, taking demonstrated bleeding episodes into account.

Documentation Required

Document Shared Decision-Making

Document that the decision regarding inability to take long-term oral anticoagulation resulted from shared decision-making between the patient and the non-implanting physician(s) involved in the patient's care, such as the primary care physician and/or primary cardiologist.

Clinical Background

Atrial fibrillation increases the risk of thromboembolic stroke because reduced and irregular atrial contraction promotes blood stasis in the left atrium. The left atrial appendage has the lowest blood flow during atrial fibrillation and is the predominant site of thrombus formation; an estimated 90% of left-atrial thrombi occur there. These thrombi can embolize and cause ischemic stroke or other systemic embolic events. Anticoagulation is the principal strategy for stroke prevention, but it may increase bleeding risk and create monitoring, dose-adjustment, or reversibility concerns.

Risk Scores and Anatomical Terms

Atrial Fibrillation Stroke-Risk Scores

PurposeCHADS2 and CHA2DS2-VASc are risk-stratification scores used to calculate stroke risk in patients with atrial fibrillation

CHADS2Assigns points for congestive heart failure, hypertension, age greater than 75, diabetes, and stroke, transient ischemic attack, or thromboembolism

CHA2DS2-VAScIncludes congestive heart failure, hypertension, diabetes, stroke, transient ischemic attack, or thromboembolism, plus age greater than or equal to 65, vascular disease, and gender category

Left Atrial Appendage

AnatomyThe left atrial appendage is an area of the left atrium

Blood flow during atrial fibrillationIt has the lowest blood flow in the left atrium during atrial fibrillation

Policy Summary

PayerUnivera Healthcare

PolicyLeft Atrial Appendage Closure Devices

Policy CodePolicy 7.01.92

Change TypeNo material change

Effective DateSeptember 17, 2026

Last ReviewSep 17, 2026

Next Review DateSeptember 1, 2027

Key ActionDocument the patient's suitability for short-term oral anticoagulation and inability to take long-term oral anticoagulation in the medical record.

SourceLink

On This Page

In patients with atrial fibrillation undergoing cardiac surgery who have a CHA2DS2-VASc score of at least 2 or equivalent stroke risk, the benefit of surgical LAA exclusion without continued anticoagulation to reduce stroke and systemic embolism risk is uncertain.

Class 2b recommendation; Level of Evidence A.

CHA2DS2 score ≥2 with moderate to high stroke risk

Anticoagulation contextSurgical LAA exclusion is indicated in addition to continued anticoagulation; benefit without continued anticoagulation is uncertain

Residual Surgical LAA Stump

Residual stumpLess than 1 cm

Suture lineAbsence of flow across the suture line

Assessment methodIntraoperative transesophageal echocardiography

Denial Risk

Percutaneous Criteria Not Met

Percutaneous left atrial appendage closure devices are considered investigational when the applicable medical-appropriateness criteria are not met.

Denial Risk

Investigational Surgical Device Use

Surgical left atrial appendage exclusion devices, including AtriClip, are considered investigational for stroke prevention in individuals with atrial fibrillation when used as a stand-alone procedure or during a thoracoscopic cardiac procedure.

Stand-alone surgical procedure
Thoracoscopic cardiac procedure

Denial Risk

Device Lacks FDA Approval for LAA Closure

All LAAO devices and related components require FDA approval before marketing and use in the United States. A device that lacks FDA approval for LAA closure may be denied; the Amplatzer cardiac plug is FDA-approved for closure of atrial septal defects but has not received FDA approval for LAA closure.

FDA-approved percutaneous LAA closure devices identified in the policy include Watchman, Watchman FLX, and Amplatzer Amulet.
Do not treat FDA approval for another indication as approval for LAA closure.

Billing Rule

Experimental/Investigational Surgical Codes

CPT codes 33267 and 33269 are designated experimental/investigational and may be denied. Verify coverage before billing surgical left atrial appendage exclusion services.

33267 — Exclusion of left atrial appendage, open, any method
33269 — Exclusion of left atrial appendage, thoracoscopic, any method

Thrombus riskIt has the highest risk of thrombosis; an estimated 90% of left-atrial thrombi occur in the left atrial appendage

CHADS2

PurposeA stroke-risk stratification score used in patients with atrial fibrillation

ComponentsCongestive heart failure, hypertension, age greater than 75, diabetes, and stroke, transient ischemic attack, or thromboembolism

Policy thresholdA CHADS2 score ≥2 identifies moderate to high stroke risk for percutaneous LAA occlusion

CHA2DS2-VASc

PurposeA stroke-risk stratification score used to calculate stroke risk in patients with atrial fibrillation

Shared components with CHADS2Congestive heart failure, hypertension, diabetes, and stroke, transient ischemic attack, or thromboembolism

Additional componentsAge greater than or equal to 65, vascular disease, and gender category

Policy thresholdA CHA2DS2-VASc score ≥2 supports the specified LAA closure criteria

HAS-BLED

PurposeA bleeding-risk score for patients with atrial fibrillation treated with warfarin

ComponentsHypertension; abnormal renal or liver function; stroke; bleeding; labile international normalized ratios; age older than 65; and drug or alcohol use

Score range0 to 9

High-risk thresholdScores of 3 or greater are associated with high risk of bleeding