Cardiac Devices and Procedures for Occlusion of the Left Atrial Appendage — CPB 0791 | AETNA Coverage Update

Aetna modified CPB 0791 for left atrial appendage closure (LAAC), effective February 19, 2026. Here's what changes for billing teams.

Aetna, a CVS Health company, updated its left atrial appendage closure coverage policy under CPB 0791 in the Aetna system. The policy governs CPT codes 33267, 33268, 33269, and 33340 — covering open, thoracoscopic, and percutaneous LAAC procedures. If your facility bills for structural heart disease interventions, this update sets tighter medical necessity criteria and adds registry enrollment requirements that can trigger claim denial if missed.

Quick-Reference Table

Aetna Left Atrial Appendage Closure Coverage Criteria and Medical Necessity Requirements 2026

The real issue with this coverage policy is the layering. Aetna doesn't just ask whether your patient has atrial fibrillation. It stacks seven distinct conditions — all of which must be met — before LAAC qualifies as medically necessary. Miss one, and you're looking at a denial.

Start with the risk score. The member needs a CHADS₂ score of 2 or higher, or a CHA₂DS₂-VASc score of 2 or higher. These scores reflect stroke risk from conditions like congestive heart failure, hypertension, diabetes, prior stroke or TIA, vascular disease, and age. Document the calculated score in the chart — not just the diagnosis codes.

Second, Aetna requires formal shared decision making with an independent, non-interventional physician before the procedure. The interaction must use an evidence-based decision tool on oral anticoagulation in NVAF patients. It must be documented in the medical record. "We discussed the options" won't cut it. The tool used and the conversation need to be there.

Third — and this is where a lot of claims fall apart — LAAC is a second-line therapy. Aetna requires documented evidence that the member cannot take long-term oral anticoagulation. That means one of four things: thromboembolism while on anticoagulation at therapeutic INR, major bleeding (intracranial or significant GI) while on anticoagulation at therapeutic INR, a HAS-BLED score of 3 or more, or another absolute contraindication. A patient who "prefers not to take blood thinners" does not qualify. This is explicit in the policy.

The remaining criteria govern care delivery. The member must be under multidisciplinary team (MDT) care before and after the procedure. The procedure must happen at a hospital with an established structural heart disease (SHD) or electrophysiology (EP) program. The performing physician — whether an interventional cardiologist, electrophysiologist, or cardiovascular surgeon — must have manufacturer training on the device, have performed at least 25 transeptal puncture procedures, and maintain an ongoing volume of at least 25 transeptal procedures over a two-year period, including at least 12 LAAC procedures.

Then there's the registry requirement. The patient, the MDT, and the hospital all must be enrolled in a prospective, national, audited registry that consecutively enrolls LAAC candidates and tracks outcomes for at least four years. Tracked outcomes include stroke by type, TIA, systemic embolism, device thrombosis, major bleeding by site and severity, and death. This isn't optional documentation — it's a coverage condition.

Prior authorization is standard for procedures of this complexity and cost. Confirm prior auth requirements with your Aetna provider rep or in the Aetna provider portal before scheduling. The reimbursement exposure on a missed auth for CPT 33340 is not small.

Surgical ligation during open heart surgery (CPT 33267 and 33268) follows a simpler path. Aetna considers that medically necessary for AF patients with a CHADS₂ or CHA₂DS₂-VASc score of at least 2 who are already undergoing open heart surgery and who will continue long-term anticoagulation. The standalone closure criteria above don't apply in that context.

Aetna Left Atrial Appendage Closure Exclusions and Non-Covered Indications

Aetna does not consider LAAC medically necessary for patients who can safely take long-term oral anticoagulants. The policy is explicit: LAAC is a second-line therapy. Patients who are candidates for anticoagulation but decline it on preference grounds do not meet the criteria.

Standalone LAA ligation — performed as its own procedure outside of open heart surgery — sits in a grayer zone. The open surgical codes (33267, 33268) are covered when performed as part of a concomitant cardiac procedure. Billing them as standalone surgeries without the accompanying procedure context is likely to generate a denial.

Any LAAC device that lacks FDA Premarket Approval (PMA) for its specific indication is not covered under this policy. That matters as new devices enter the market. If you're using a device that has clearance but not full PMA, check before billing CPT 33340.

Coverage Indications at a Glance

Aetna Left Atrial Appendage Closure Billing Guidelines and Action Items 2026

These are the steps your billing team and clinical staff need to take now. The effective date is February 19, 2026. If cases are already scheduled, audit them before they go to the floor.

CPT, HCPCS, and ICD-10 Codes for Left Atrial Appendage Closure Under CPB 0791

Covered CPT Codes (When Selection Criteria Are Met)

Other CPT Codes Related to This Policy

Key ICD-10-CM Diagnosis Codes

The stroke and cerebrovascular codes (I63.xx and I66.xx) show up here because prior stroke or TIA is part of both the CHADS₂ and CHA₂DS₂-VASc scoring that drives medical necessity. Accurate coding of prior stroke history is part of your supporting diagnosis documentation, not just clinical context.