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    OpenPayerPolicy UpdatesAnesthesiologyAetna Autotransfusers Coverage Policy Update | Ope…
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    CurrentAetnaPolicy 0639

    Autotransfusers Clinical Policy Bulletin

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    Defines Aetna's medical necessity criteria for autotransfusion and cell saver devices, lists covered CPT/HCPCS/ICD-10 codes when selection criteria are met, describes indications considered medically necessary vs experimental/investigational, and provides clinical background and evidence summary. This is Part 1 of 2 of the bulletin.

    Policy Summary
    PayerAetna
    PolicyAutotransfusers Clinical Policy Bulletin
    Policy CodePolicy 0639
    Change TypeNo material change
    Effective DateAug 20, 2002
    Last ReviewSep 13, 2023
    Next Review DateJul 11, 2024
    Key ActionDocument the clinical indication and estimated blood loss/anticipated need for transfusion to support medical necessity; CPT codes 86890 and 86891 are covered only if selection/medical necessity criteria are met.
    SourceLink

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    POLICY UPDATE CHANGES

    No material clinical or coverage changes identified (has_material_change=false).

    3Medically Necessary Indication Categories
    >=2Min expected blood units threshold
    manyICD-10 examples listed
    2023-09-13Last Review
    2024-07-11Next Review

    Coverage Summary

    Overview: This policy (Policy Number 0639) on Autotransfusers (cell salvage/autotransfusion devices) defines Aetna's medical necessity criteria as mixed (some indications medically necessary; others investigational). Effective date: 2002-08-20; Last review: 2023-09-13; Next review: 2024-07-11.

    Indications and thresholds: There are 3 medically necessary indication categories (emergency/intra-operative autotransfusion; hemodilution/cell washing autotransfusion; post-operative autotransfusion, usually within 2 hours). Devices are not considered medically necessary for procedures expected to require < 2 units of blood; the expected transfusion volume threshold for consideration is >= 2 units.

    Thresholds & Review Dates
    Expected transfusion volume thresholdProcedure expected to require >= 2 units of blood
    Typical post-operative reinfusion windowUsually done within 2 hours (post-operative autotransfusion)
    Effective Date2002-08-20
    Last Review2023-09-13
    Next Review2024-07-11

    Medical Necessity

    Medical Necessity

    Aetna considers the following autotransfusion and cell saver devices medically necessary for procedures that may deplete blood volume:

    ANY of the following

    • Emergency or intra-operative autotransfusion, where blood is collected from the wound or a body cavity, processed, and then returned to the individual.
    • Hemodilution or cell washing autotransfusion, where blood is collected and simultaneously replaced with sufficient volume of crystalloid or colloid solution.
    • Post-operative autotransfusion (usually done within 2 hours with a chest tube collection device), where the blood from the chest (or other sterile operative sites) is re-infused following heart surgery and traumatic hemithorax.2 hours

    Coding

    Covered CPT codes if selection criteria are metCPTCovered
    86890Autologous blood or component, collection processing and storage; predeposited.
    86891Autologous blood or component, collection processing and storage; intra- or postoperative salvage.
    ICD-10 codes covered if selection criteria are met (not all-inclusive)ICD-10Covered
    D62Acute posthemorrhagic anemia.
    O00.00 - O00.91Ectopic pregnancy.
    O08.1Delayed or excessive hemorrhage following ectopic and molar pregnancy.
    O44.10 - O44.13Placenta previa with hemorrhage.
    O45.001 - O45.099Premature separation of placenta with coagulation defect.
    O46.001 - O46.099Antepartum hemorrhage with coagulation defect.
    O67.0Intrapartum hemorrhage with coagulation defect.
    O72.0Third-stage hemorrhage.
    O72.1Other immediate postpartum hemorrhage.
    O72.2Delayed and secondary postpartum hemorrhage.
    1–10 of 23
    1/3

    Provider Actions & Billing Impact

    Prior Authorization

    Selection criteria must be met for CPT coverage

    CPT codes 86890 and 86891 are covered only if the policy's selection/medical necessity criteria are met — e.g., for procedures likely to deplete blood volume or when the procedure is expected to require ≥2 units of blood or for one of the listed indications.

    • Codes: 86890, 86891
    Documentation Required

    Indication documentation

    Document the clinical indication (for example: emergency or intra-operative salvage, hemodilution/cell washing, or post-operative chest-tube reinfusion after cardiac surgery or traumatic hemithorax) and document estimated blood loss and the anticipated need for transfusion to support medical necessity.

    Background & Evidence Summary

    Background: Autotransfusers (cell salvage or "cell saver" devices) mechanically collect and re-infuse a patient’s own blood lost during surgery; modalities include intra-operative/emergency salvage, post-operative salvage (often reinfused within 2 hours using chest tube collection devices) and hemodilution/cell-washing techniques.

    Contraindications and mitigation: Autotransfusion is contraindicated when collected blood is exposed to bacteria (e.g., infected wounds, fecal contamination) or contains malignant cells. Limited studies note that leukocyte depletion filters or blood irradiation may mitigate tumor cell contamination risk, but evidence is limited and use in oncologic or contaminated fields requires caution.

    Evidence summary: Systematic reviews and randomized trials (meta-analyses in cardiac and other surgeries) demonstrate that cell salvage generally reduces exposure to allogeneic blood in many settings (cardiac, orthopedic, vascular, some joint and spine procedures) though effects on mortality and major complications are not shown; overall evidence quality is low to moderate with heterogeneous results and mixed cost-effectiveness depending on procedure and setting.

    CitationKey finding
    Huet et al (1999) meta-analysis
    Cell salvage devices decrease the proportion of patients receiving peri-operative allogeneic transfusion; mixed results for unwashed post-operative devices in cardiac surgery.
    Cochrane (Carless et al, 2003)
    Cell salvage reduces the need for donated blood but more research needed on cost-effectiveness across surgical settings.
    Wang et al (2009) meta-analysis (cardiac)
    Reduced exposure to allogeneic blood (OR 0.63) and RBCs (OR 0.60); no difference in mortality or major complications.
    Kinnear 2018 cohort
    In open radical prostatectomy cohort, ICS did not change allogeneic transfusion rates or recurrence but reduced transfusion-related costs by fewer units transfused.
    Kinnear 2019 systematic review
    14 observational studies: ICS reduced allogeneic transfusion in prostatectomy studies (OR 0.34 vs no technique); heterogeneity limited conclusions on recurrence, complications, cost.
    So-Osman et al (2014a) randomized study
    Autologous reinfusion did not reduce RBC use in hip/knee patients with Hb 10–13 g/dL and increased costs.
    So-Osman et al (2014b) large randomized study
    In elective total hip/knee patients with pre-op Hb >13 g/dL, autologous salvage devices did not reduce RBC use and increased costs.
    Ji et al (2017) meta-analysis (TKA/THA)
    Post-operative autotransfusion reduced allogeneic transfusion vs regular drainage in TKA and THA, but not when compared with no drainage; results limited by heterogeneity.
    Waters et al (2012) meta-analysis (cancer surgery)
    Pooled OR 0.65 suggested intraoperative blood salvage outcomes not inferior to allogeneic transfusion; prospective randomized trials needed to confirm risk in cancer surgery.
    Definitions
    Autotransfusion / cell saverMechanical device/process that collects and re-infuses a patient's own blood lost during surgery; may be washed or unwashed and used intra-operatively, post-operatively, or as hemodilution.
    Post-operative autotransfusion (PAT)Reinfusion of blood collected after surgery (usually within 2 hours) from chest tubes or other sterile operative sites.

    Revision History

    2002-08-20effective

    Policy effective date

    2023-09-13last_reviewLatest

    Last review date

    2024-07-11next_review

    Next scheduled review date

    Policy Summary
    PayerAetna
    PolicyAutotransfusers Clinical Policy Bulletin
    Policy CodePolicy 0639
    Change TypeNo material change
    Effective DateAug 20, 2002
    Last ReviewSep 13, 2023
    Next Review DateJul 11, 2024
    Key ActionDocument the clinical indication and estimated blood loss/anticipated need for transfusion to support medical necessity; CPT codes 86890 and 86891 are covered only if selection/medical necessity criteria are met.
    SourceLink
    On This Page
    Coverage SummaryMedical NecessityCodingProvider Actions & Billing ImpactBackground & Evidence SummaryRevision History
    Exclusion - low expected blood loss:
    Autotransfusion and cell saver devices are NOT considered medically necessary for members undergoing procedures that are expected to require less than 2 units of blood.
    >=2 units
    Not medically necessary / investigational: Autotransfusion and cell saver devices are considered experimental and investigational for all other indications because their effectiveness for indications other than those listed above has not been established.
    Denial Risk

    Denial risk for low expected blood loss

    Claims may be denied when autotransfusion/cell saver use is for procedures expected to require less than 2 units of blood or for indications considered experimental or investigational (i.e., not among the policy’s listed medically necessary indications).

    Documentation Required

    Policy review and references available

    Refer to Aetna's Clinical Policy Bulletin (Policy Number 0639) and the cited literature (systematic reviews, randomized trials, and other references listed in the bulletin) for full policy details and supporting evidence; the bulletin is maintained and periodically updated by Aetna.