33268
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.44
Facility
$117.24
Non-Facility
$117.24
Documentation Required
- A formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in persons with non-valvular atrial fibrillation (NVAF) prior to LAAC. Additionally, the shared decision making interaction must be documented in the medical record;
- Documentation that the device has received U.S. Food and Drug Administration (FDA) Premarket Approval (PMA) for that device’s FDA-approved indication;
- Documentation of CHADS2 score (>=2) or CHA2DS2-VASc score (>=3) as applicable;
- Documentation of reason(s) why the member is 'deemed unable to take long-term oral anticoagulation' including one or more of: thromboembolism while on an oral anticoagulant (while INR therapeutic); major bleed while on an oral anticoagulant (intracranial bleed, significant GI bleeding); HAS-BLED score >= 3; or other absolute contraindication to long-term anticoagulation;
Key Coverage Criteria
- Suitability for short-term dual antiplatelet therapy or warfain for 45 days and long-term aspirin but deemed unable to take long-term oral anticoagulation for one or more of the following reasons, following the conclusion of shared decision making, as LAAC is only considered medically necessary as a second line therapy to oral anticoagulants:
- Member has thromboembolism while on an oral anticoagulant (i.e., while INR is in therapeutic range);
- or Member has major bleed (intracranial bleed, significant gastrointestinal bleeding (not just guaiac positive stools) while on an oral anticoagulant (i.e., while INR is in therapeutic range);
- or Member has elevated risk of bleeding on oral anticoagulant with a HAS-BLED score of 3 or more;
- or Member has other absolute contraindication to long-term anticoagulation;
- The member (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT) of medical professionals;
3 Active Policies
AETNA-CPB-0791 — Cardiac Devices and Procedures for Occlusion of the Left Atrial Appendage
HUMANA-LEFT-ATRIAL-APPENDAGE-AND-CARDIAC-STRUCTURAL-DEFECT-CLOSURE-MA — Left Atrial Appendage and Cardiac Structural Defect Closure - Medicare Advantage
ANTHEM-SURG.00032 — SURG.00032 Patent Foramen Ovale and Left Atrial Appendage Closure Devices
Related Codes
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