Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Atrial Fibrillation
Treatment: Closure of left atrial appendage
The insurer denied the Closure of left atrial appendage.
The denial is overturned. 

The patient is a male with a history of hypertension, obesity, hyperthyroidism and long standing persistent atrial fibrillation. He underwent left atrial catheter ablation with electrical isolation of the pulmonary veins and posterior wall, along with cavo-tricuspid isthmus ablation.  The procedure was uncomplicated, and the patient was discharged in sinus rhythm on Eliquis therapy.  

Recommendations were subsequently made for left atrial appendage occlusion.  Additional medical records provided reveal a history of intolerance to Eliquis therapy characterized by heavy hemorrhoidal bleeding and recurrent skin ecchymosis.

Yes, the health plan should cover the proposed treatment.

The records state that the patient cannot be treated with oral anticoagulant therapy due to "intolerance".  Additional records note that the patient has developed recurrent and substantial ecchymosis and heavy hemorrhoidal bleeding while on Eliquis therapy.

Yes, the requested 33340 (close of left atrial appendage) (left atrial appendage occlusion) is likely to be more beneficial than any standard treatment(s). 

This patient had an elevated CHADSVASC (Congestive Heart Failure, High blood pressure, Age, Diabetes, Previous stroke or clot, Vascular disease, Age, Sex) score, indicating that he has a significant risk of stroke following a diagnosis of atrial fibrillation. To reduce the risk of stroke, oral anticoagulant medications were appropriately prescribed. Left atrial appendage occlusion has been shown to be non-inferior to warfarin therapy in preventing stroke in patients with atrial fibrillation. (References 2-5)  Current guidelines recommend considering transcatheter left atrial appendage occlusion in patients that suffer from atrial fibrillation, have an elevated risk of stroke, and a contraindication to oral anticoagulant therapy due to an elevated risk of bleeding. (Reference 6)  Current Food and Drug Administration (FDA) guidelines approve the use of the Watchman device in patients that have an elevated risk of stroke based on the CHADSVASC (Congestive Heart Failure, High blood pressure, Age, Diabetes, Previous stroke or clot, Vascular disease, Age, Sex) score and have appropriate rationale to seek an alternative to long term anticoagulant therapy.  

Given additional records, there is documentation of intolerance to oral anticoagulant therapy (heavy hemorrhoidal bleeding and extensive recurrent skin ecchymosis). This patient has an elevated risk of thromboembolic stroke given his CHADVASC (Congestive Heart Failure, High blood pressure, Age, Diabetes, Previous stroke or clot, Vascular disease, Age, Sex) score and his history of persistent atrial fibrillation (AF) as well as an elevated HASBLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) score with intolerance to oral anticoagulant therapy at appropriate doses.  In conclusion, left atrial appendage occlusion is likely to be more beneficial than continued oral anticoagulant therapy.