Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for heart surgery to repair the left atrial appendage, including the placement of a Watchman device to close the left atrial appendage. The records document that this patient has persistent atrial fibrillation. Given the patients presentation, he has a congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex category (CHADSVASC) score of 3, supporting an indication for anticoagulation to prevent embolic stroke. He is currently on dabigatran anticoagulation therapy. However, he also has a history of peripheral neuropathy and is unsteady on his feet. He has reportedly had multiple prior falls and has sustained at least one head injury. In patients who require long-term anticoagulation, but are at risk for bleeding, the most recent randomized and meta-analysis data suggests that the Watchman device is non-inferior to anticoagulation with regard to embolic stroke risk. In addition, the Watchman device may be indicated when therapeutic anticoagulation carries an excessive risk. Given the patients neuropathy and recurrent falls, insertion of a Watchman device will provide stroke risk protection while allowing him to discontinue long-term anticoagulation. Moreover, the Watchman device has U.S. Food and Drug Administration (FDA) approval for use in this specific clinical setting. All told, the requested heart surgery to repair the left atrial appendage, including the placement of a Watchman device to close the left atrial appendage, is likely to be more beneficial for treatment of this patients medical condition than standard long-term anticoagulation therapy.Findings:  Three physician reviewers found the requested heart surgery to repair the left atrial appendage, including the placement of a Watchman device to close the left atrial appendage is likely to be more beneficial for treatment of this patients medical condition than standard long-term anticoagulation therapy.Final Result: Three of three reviewers determined that the requested heart surgery to repair the left atrial appendage, including the placement of a Watchman device to close the left atrial appendage is likely to be more beneficial for treatment of this patients medical condition than standard long-term anticoagulation therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in cardiovascular disease with subspecialty certification in interventional cardiology and are actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and interventional cardiology and are actively practicing. Physician reviewer 3 is board certified in internal medicine and subspecialty certifications in cardiovascular disease and cardiac electrophysiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.