CurrentAetnaPolicy 0639

Autotransfusers Clinical Policy Bulletin

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

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

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

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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

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

86890	Autologous blood or component, collection processing and storage; predeposited.
86891	Autologous 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

D62	Acute posthemorrhagic anemia.
O00.00 - O00.91	Ectopic pregnancy.
O08.1	Delayed or excessive hemorrhage following ectopic and molar pregnancy.
O44.10 - O44.13	Placenta previa with hemorrhage.
O45.001 - O45.099	Premature separation of placenta with coagulation defect.
O46.001 - O46.099	Antepartum hemorrhage with coagulation defect.
O67.0	Intrapartum hemorrhage with coagulation defect.
O72.0	Third-stage hemorrhage.
O72.1	Other immediate postpartum hemorrhage.
O72.2	Delayed and secondary postpartum hemorrhage.

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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.

Citation	Key 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)

Revision History

2002-08-20effective

Policy effective date

2023-09-13last_reviewLatest

Last review date

2024-07-11next_review

Next scheduled review date