Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Surgery (atrial appendage occlusion): 33340x1.
The insurer denied the Surgery (atrial appendage occlusion): 33340x1.
The denial is upheld

This patient is a male with chronic atrial fibrillation. The patient was referred for a left atrial appendage (LAA) occlusion (33340x1). His past medical history (PMH) is remarkable for hypertension, gastroesophageal reflux disease (GERD), chronic kidney disease and liver cancer treated with partial liver lobectomy surgery complicated by anemia requiring multiple blood transfusions. The patient had a gastrointestinal (GI) bleed while on Coumadin anticoagulation. The patient had difficulty maintaining a therapeutic international normalized ratio (INR) requiring multiple blood transfusions.

The patient's congestive heart failure, hypertension, age greater than or equal to 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, and sex category score (CHA2DS2-VASc) is one. The patient underwent a successful pulmonary vein isolation (PVI) atrial fibrillation catheter ablation and Eliquis five milligrams twice a day (mg bid) was initiated without bleeding issues.

No, the proposed treatment, left atrial appendage (LAA) occlusion procedure, is not "medically necessary."

The left atrial appendage (LAA) occlusion procedure is unproven, and therefore, not medically necessary. Left atrial appendage closure devices, such as the Watchman, have been considered a mechanical method to prevent stroke in those with atrial fibrillation (Afib) requiring anticoagulation, that have an increased risk for stroke and that are recommended for anticoagulation, both as a substitute for anticoagulation and for individuals with a contraindication to anticoagulation, along with a congestive heart failure, hypertension, age greater than or equal to 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, and sex category score (CHA2DS2-VASc) of two for men and three for women.

However, it has not been established as the standard of care towards improved atrial fibrillation (Afib) outcomes compared to oral anticoagulation for a congestive heart failure, hypertension, age greater than or equal to 75 years, diabetes mellitus, stroke or transient ischemic attack (TIA), vascular disease, age 65 to 74 years, and sex category score (CHA2DS2-VASc) of one and an individual tolerating oral anticoagulation with Eliquis as in this patient's case. Also, there is the expectation in this patient's case, that oral anticoagulant (OAC) will be short-term only, given the history provided of having recent successful pulmonary vein isolation (PVI) atrial fibrillation catheter ablation procedure.

Therefore, the proposed treatment, left atrial appendage (LAA) occlusion procedure is not medically necessary, based on the submitted clinical information in the current published medical evidence based guidelines.
The request for coverage for left atrial appendage (LAA) occlusion procedure has been denied as not medically necessary and the patient is appealing the decision.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.