Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that the Centers for Medicare & Medicaid Services (CMS) covers percutaneous LAAC for non-
valvular atrial fibrillation (NVAF) through Coverage with Evidence Development (CED) with the following 
conditions: 
a. LAAC devices are covered when the device has received Food and Drug Administration (FDA) Premarket 
Approval (PMA) for that device's FDA-approved indication and meet all of the conditions specified below: 
 
The patient must have: 
o A CHADS2 score equals 2 (Congestive heart failure, Hypertension, Age greater than 75, Diabetes, 
Stroke/transient ischemia attack/thromboembolism) or CHA2DS2- VASc score equals 3 (Congestive heart 
failure, Hypertension, Age equals 65, Diabetes, Stroke/transient ischemia attack/thromboembolism, Vascular 
disease, Sex category) 
o A formal shared decision making interaction with an independent non-interventional physician using an 
evidence-based decision tool on oral anticoagulation in patients with NVAF prior to LAAC. Additionally, the 
shared decision making interaction must be documented in the medical record. 
o A suitability for short-term warfarin but deemed unable to take long-term oral anticoagulation following the 
conclusion of shared decision making, as LAAC is only covered as a second line therapy to oral anticoagulants. 
The patient (preoperatively and postoperatively) is under the care of a cohesive, multidisciplinary team (MDT) 
of medical professionals. The procedure must be furnished in a hospital with an established structural heart 
disease (SHD) and/or electrophysiology (EP) program. 
 
You can find this information in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual Section 20.34. 
Coverage Guidance 
 
The rules say Covered Indications: 
 
Transesophageal echocardiogram will be considered medically necessary in any of the following 
circumstances: 
 Examination of prosthetic heart valves, primarily mitral 
Arrhythmias - assessment of patients with certain cardiac arrhythmias [atrial fibrillation, atrial flutter] for 
which the results of the test will influence treatment decisions. TEE may complement transthoracic 
echocardiography particularly to assess for left atrial thrombus. 
Detection of: 
aortic dissection 
atrial septal defect 
congenital heart disease 
embolism or thrombosis, primarily involving left atrium 
intracardiac foreign bodies, tumors or masses 
mitral valve regurgitation 
vegetative endocarditis 
Intra-operative guide to left ventricular function 
Inadequacy of transthoracic echo due to: 
chest wall deformity, COPD 
open heart or chest surgery 
chest trauma 
obesity 

Limitations 
 
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the 
Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under 
which the item or service is considered reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD): Transesophageal 
Echocardiography (TEE) (L33756). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.