Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Angiodysplasia, atrial fibrillation.
Treatment: Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The insurer denied the Procedure code 33340 - heart surgery (transcatheter closure of the left atrial appendage) and one day inpatient hospital admission, Pre-service.
The denial is overturned. 

The patient is a female with angiodysplasia leading to anemia. She has a history of atrial fibrillation, and multiple arteriovenous malformations (AVMs) requiring transfusions. The patient underwent cauterization and her anemia stabilized. She remained in atrial fibrillation and was symptomatic. Echocardiogram showed normal left ventricular (LV) function. Electrocardiogram (EKG) showed atrial fibrillation. Her 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, sex category (CHAD-VASC) score was three-plus (3+). A request was made for percutaneous closure of atrial appendage (WATCHMAN).

The request was denied by the health plan as investigational.

Yes, the health plan should cover the proposed treatment.
The consensus of Cardiology papers both here and abroad have recommended the use of left atrial appendage (LAA) closure (WATCHMAN) on patients who have atrial fibrillation and have high bleeding risk on anti-coagulation. For example  "A consensus statement from the European Heart Rhythm Association and the European Association of Percutaneous Cardiovascular Interventions states that LAA occlusion is acceptable in patients with a contraindication to oral anticoagulation (OAC) or those who are unwilling or unable to take OAC". UP-TO-DATE recommendation is "For patients with AF with an indication for oral anticoagulation (based upon their estimated risk of stroke and other thromboembolic events) who have a contraindication to long-term oral anticoagulation, we suggest placement of a percutaneous LAA occlusion device."

This patient has an increased risk of bleeding including recent gastrointestinal (GI) bleed to a hemoglobin of eight.  The natural history of arteriovenous malformation (AVM) is recurrent bleeding. Due to the patient's now persistent atrial fibrillation, she needs to be on anti-coagulation. She would benefit from the device.

In current cardiology practices, the device is not considered experimental.  This patient would routinely have the device placed without any institutional review board (IRB) requirements; the only stipulation is that an active database is kept.

In patients with a chronic increased risk of bleeding, who requires anti-coagulation for atrial fibrillation due to 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, sex category (CHAD-VASC) score, percutaneous closure is considered more beneficial than either chronic anti-coagulation, or no treatment.

Yes, the requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease.
In patients with a chronic increased risk of bleeding, who requires anti-coagulation for atrial fibrillation due to 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, sex category (CHAD-VASC) score, percutaneous closure is considered more beneficial than either chronic anti-coagulation, or no treatment.