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

1. Emergency or intra-operative autotransfusion, where blood is collected from the wound or a body cavity, processed, and then returned to the individual.
2. Hemodilution or cell washing autotransfusion, where blood is collected and simultaneously replaced with sufficient volume of crystalloid or colloid solution.
3. 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.

Aetna considers autotransfusion and cell saver devices experimental and investigational for all other indications because their effectiveness for indications other than the ones listed above has not been established.

Note: 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.

Examples of procedures that may involve major blood loss and may require autologous blood transfusions or the use of autotransfusers include, but are not limited to: 

1. Cardiopulmonary bypass surgery and other high-risk cardiac surgeries (e.g., abdominal aortic surgery)
2. Ectopic pregnancy
3. Emergency hemorrhage
4. Hysterectomy
5. Organ transplantation
6. Orthopedic surgery
7. Post-operative hemorrhage
8. Vascular femoral grafts.

An autotransfuser is a mechanical device that is used in the process of collecting and re-infusing blood lost from hemorrhage.  Different forms of autologous transfusers include intra-operative, emergency, or post-operative salvage devices and hemodilution devices used to re-infuse a patient's own blood.

Many people have safety concerns about receiving transfusions of donated blood.  "Cell salvage" with autotransfusion is a technique designed to reduce the need for such transfusions.  The technique involves collecting blood from surgical sites, to be transfused back into the person during or after surgery if necessary.  The blood is either "washed" before transfusion or transfused directly after being filtered (unwashed).  Risks from cell salvage include infection and blood clotting problems.

Autologous blood transfusion or the use of autotransfusers are contraindicated in blood exposed to bacteria (an infected wound or blood with fecal contamination) or in blood with malignant cells.

A meta-analysis of studies of cell savers in cardiac and orthopedic surgery (Huet et al, 1999) found that both devices that wash and do not wash salvaged blood decrease the proportion of patients who receive a peri-operative allogeneic transfusion.  These investigators found, however, that the post-operative use of devices that do not wash salvaged blood in cardiac surgery was only marginally effective.  The authors noted that cell salvage did not appear to increase adverse events, although side-effects were inconsistently reported and the number of patients studied was relatively small.

A Cochrane evidence review (Carless et al, 2003) found evidence suggesting that cell salvage reduces the need for transfusions of donated blood.  However, the investigators concluded that better quality research is needed to assess the cost-effectiveness of cell salvage across a range of surgical settings compared to other blood-sparing techniques.

Reitman et al (2004) evaluated the necessity and cost-effectiveness of the use of Cell Saver for adult lumbar spine fusions.  These investigators concluded that while patients in the Cell Saver group did require fewer post-operative transfusions, the difference was not as much as expected.  In elective fusions for degenerative conditions of the lumbar spine, blood requirements can usually be satisfied with pre-donation of autologous blood.  With contemporary practices of pre-donation, the use of the Cell Saver appears to be neither necessary nor cost-effective during most elective lumbar fusions.

Gause et al (2008) examined the effectiveness of using intra-operative Cell Saver in decreasing the need for blood transfusion.  Data were collected from 188 patients undergoing consecutive instrumented lumbar laminectomy and fusion.  A total of 141 of these patients had Cell Saver used during their procedures, whereas 47 did not.  In addition, previously published data from similarly treated patients were used for analysis.  Operative blood loss, autologous and allogeneic blood transfusions, discharge hematocrit, and patient factors were analyzed.  A significant increase in the number of blood transfusions was found in the Cell Saver group, which also had a significantly increased blood loss compared with the non-Cell Saver group.  Using analysis of co-variance, these investigators determined the effect of blood loss on the need for transfusion.  The results showed that correcting for blood loss eliminated the significance in the transfusion difference, but Cell Saver still was not able to decrease the transfusion need.  Comparing their current results with their previously published results also demonstrated no benefit of Cell Saver use.  The authors concluded that the use of Cell Saver in instrumented lumbar fusion cases was not able to decrease the need for blood transfusion.  Furthermore, Cell Saver use was associated with a significantly higher blood loss.

In a retrospective review, Scannell et al (2009) examined if Cell Saver use in patients with acetabular fractures reduces the volume or rate of allogeneic blood transfused intra-operatively and post-operatively and if this translated to a decrease in blood-related charges to the patient.  A total of 186 patients with operatively treated acetabular fractures were included in this study.  All patients underwent open reduction internal fixation of their acetabular fracture.  The decision to use Cell Saver was at the surgeon's discretion.  The volume and rate of intra-operative and post-operative allogeneic blood transfused and blood-related charges were evaluated.  Cell Saver was used in 60 cases (32 %), and the average volume of blood autotransfused was 345 ml.  No differences were observed in the rates (58.3 % versus 48 %, p = 0.1883) or the mean volumes (770 versus 518 ml, p = 0.0537) of intra-operative and post-operative allogeneic blood transfusions between the Cell Saver and the non-Cell Saver groups.  Total blood-related charges in the Cell Saver group were significantly higher than that in the non-Cell Saver group ($1,958 versus $694, p < 0.0001).  Sub-analyses based on fracture pattern, injury severity score, body mass index, days to surgery, and estimated blood loss were performed.  In each sub-analyses, no differences were observed in intra-operative and post-operative transfusion rates and volumes, and total blood-related charges were higher in the Cell Saver groups.  The authors concluded that in the routine use of Cell Saver in acetabular surgery, there was no reduction in the volume or rate of allogeneic blood transfused intra-operatively or post-operatively.  However, blood-related charges were significantly increased.

In a systematic review and meta-analysis of published randomized controlled trials, Wang et al (2009) examined the overall safety and effectiveness of cell salvage in cardiac surgery.  Medline, Cochrane Library, Embase, and abstract databases were searched up to November 2008.  All randomized trials comparing Cell Saver use and no Cell Saver use in cardiac surgery and reporting at least 1 pre-defined clinical outcome were included.  The random effects model was used to calculate the odds ratios (OR, 95 % confidence intervals [CI]) and the weighted mean differences (WMD, 95 % CI) for dichotomous and continuous variables, respectively.  A total of 31 randomized trials involving 2,282 patients were included in the meta-analysis.  During cardiac surgery, the use of an intra-operative Cell Saver reduced the rate of exposure to any allogeneic blood product (OR 0.63, 95 % CI: 0.43 to 0.94, p = 0.02) and red blood cells (OR 0.60, 95 % CI: 0.39 to 0.92, p = 0.02) and decreased the mean volume of total allogeneic blood products transfused per patient (WMD -256 ml, 95 % CI: -416 to -95 ml, p = 0.002).  There was no difference in hospital mortality (OR 0.65, 95 % CI: 0.25 to 1.68, p = 0.37), post-operative stroke or transient ischemia attack (OR 0.59, 95 % CI: 0.20 to 1.76, p = 0.34), atrial fibrillation (OR 0.92, 95 % CI: 0.69 to 1.23, p = 0.56), renal dysfunction (OR 0.86, 95 % CI: 0.41 to 1.80, p = 0.70), infection (OR 1.25, 95 % CI: 0.75 to 2.10, p = 0.39), patients requiring fresh frozen plasma (OR 1.16, 95 % CI: 0.82 to 1.66, p = 0.40), and patients requiring platelet transfusions (OR 0.90, 95 % CI: 0.63 to 1.28, p = 0.55) between Cell Saver and non-Cell Saver groups.  The authors concluded that current evidence suggests that the use of a cell saver reduces exposure to allogeneic blood products or red blood cell transfusion for patients undergoing cardiac surgery.  Sub-analyses suggest that a Cell Saver may be beneficial only when it is used for shed blood and/or residual blood or during the entire operative period.  Processing cardiotomy suction blood with a Cell Saver only during cardiopulmonary bypass has no significant effect on blood conservation and increases fresh frozen plasma transfusion.

Savvidou et al (2009) examined the use of cell saver blood autotransfusion in spinal surgery and evaluated the effectiveness and cost-effectiveness of cell saver blood autotransfusion during lumbar spine fusion in adults.  A total of 50 consecutive candidates for postero-lateral fusion with internal fixation were prospectively randomized into either receiving peri-operatively cell saving autotransfusion (group A: 25 patients) or not (group B: 25 patients).  The use of cell saving technique did not exclude the use of allogenic blood transfusion.  Surgical indications were spinal stenosis, spondylolisthesis, adolescent idiopathic scoliosis, degenerative scoliosis and fractures.  Medical and financial data were recorded.  A cost-analysis was performed.  Patients in group A received 880 +/- 216 ml from cell saver and 175 +/- 202 ml allogenic blood.  The patients in group B received 908 +/- 244 ml allogenic blood.  Blood volumes data collected were expressed in mean +/- SD values.  The cost of blood transfusion in group A was 995 +/- 447 Euro per patient and 1,220 +/- 269 in group B (p < 0.05).  The authors concluded that in elective lumbar fusion blood requirements can be satisfied with the use of autotransfusion.  The use of cell saver appears to be useful and cost-effective during most elective lumbar fusions.

Bowen et al (2010) examined the effectiveness of intra-operative cell salvage systems in pediatric idiopathic scoliosis patients undergoing posterior spinal fusion with segmental spinal instrumentation.  A total of 54 consecutive patients were studied: 21 non-cell saver and 33 cell saver patients.  Data included age, body mass index, Cobb angle, peri-operative hemoglobin levels, mean arterial pressure, surgical time, levels fused, peri-operative estimated blood loss, and peri-operative transfusions.  A Chi square and t- tests were performed for intra-operative and peri-operative allogeneic transfusion between groups.  A regression analysis was performed between selected co-variates and allogeneic transfusion.  Relative risk analysis examined significant co-variates regarding allogeneic transfusion rate.  Allogeneic transfusion rates were lower in the cell saver group (6 % versus 55 % intra-operative and 18 % versus 55 % peri-operative, p < 0.05).  Mean allogeneic transfusion volumes (ml/kg) were also lower (0.4 versus 9.1 intra-operative and 1.9 versus 11.1 peri-operative, p < 0.05).  Multi-variate analysis confirmed these differences were independent of peri-operative blood loss, and also demonstrated that surgical time and blood loss were significantly related to allogeneic transfusion volume.  The allogeneic transfusion relative risk was 2.04 in patients with surgery greater than 6 hours and 5.87 in patients not receiving cell saver blood.  All patients with surgeries greater than 6 hours and estimated blood loss greater than 30 % of total blood volume received cell saver system blood.  The authors concluded that cell saver use decreased allogeneic transfusion, particularly in surgeries greater than 6 hours with estimated blood loss greate than 30 % of total blood volume.  This study confirmed the utility of routine cell saver use during posterior spinal fusion with segmental spinal instrumentation for idiopathic scoliosis.

Anderson and Panizza (2010) noted that endoscopic transnasal approaches to the skull base and intra-cranial disease are an emerging subspecialty.  The limits of this approach are often dictated by exposure and blood loss.  Cell salvage techniques are widely used in other surgical fields.  However, in otolaryngology, questions remain regarding its safety because work is performed in a contaminated field.  These researcehers presented the evidence for peri-operative cell saver blood transfusion in potentially contaminated fields and the need for further investigation of its use in endonasal surgery.  Medline and evidence-based medicine reviews databases were searched for relevant articles.  All English articles discussing autologous blood transfusion in endonasal surgery were reviewed.  Despite a wide search pattern, no articles that discuss this topic were found in the English literature.  Therefore, these investigators went on to present data on the general use of cell saver blood in contaminated fields.  The authors concluded that cell saver blood is widely accepted in surgery.  It offers many advantages in elective operations in which blood loss is expected to be significant.  Cell saver blood has been transfused from contaminated fields in other forms of surgery without an associated increase in morbidity.  There is good evidence that antibiotic prophylaxis is mandatory in this setting.  There is no direct evidence that cell salvage blood is safe in endonasal surgery.

Reyes and colleagues (2011) examined if the use of cell saver (CS) systems reduce the need of blood products in low-risk patients undergoing cardiac surgery.  Between February and June 2009, all low-risk patients (EuroSCORE less than 10 %) undergoing coronary or valve procedure were selected (n = 63).  Exclusion criteria were: combined procedure, aorta procedure, redo surgery, emergency procedures, creatinine levels greater than 2 mg/ml, anemic patients and patients with a body surface area (BSA) less than 1.6 m2.  Patients were randomized to undergo cardiac surgery with a CS system (group CS; n = 34) or without (control group [CO]; n = 29).  All patients received tranexamic acid during the procedure.  Need of blood products and clinical outcomes were analyzed in both groups.  Mean age was 64.7+/- 12.3 years old with 33 % of female patients.  Baseline clinical characteristics and pre-operative blood count cell were similar in both groups.  Mean CS blood re-infused was 461 +/- 174 ml (maximum: 985; minimum: 259).  A total of 59 red blood packages were transfused in 25 patients (mean of 1.02 +/- 1.3; range of 0 to 5).  The proportion of patients being transfused was similar in both groups (CS: 40 % versus CO: 46.4 %; p = 0.79).  Eleven plasma packages were transfused (CS: 8 versus CO: 3; p = 0.77) and 3 platelet pools were used in group CS and none in group CO (p = 0.08).  Multi-variate analysis showed that pre-operative hemoglobin levels greater than 13.3 g/dL (relative risk [RR]: 0.29; CI: 0.09 to 0.99) and BSA greater than 1.74 (RR: 0.19; CI: 0.54 to 0.68) were protective against blood transfusion.  The authors concluded that in low-risk patients CS system did not reduce the need of blood transfusion.  Clinical outcomes were similar regardless of the use of a CS system.  A low pre-operative hemoglobin level and a low BSA were related with the use of blood products.

The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists' updated clinical practice guideline on "Blood Conservtion" (Ferraris et al, 2011) noted that during cardiopulmonary bypass, intra-operative autotransfusion, either with blood directly from cardiotomy suction or recycled using centrifugation to concentrate red cells, may be considered as part of a blood conservation program.

Shantikumar et al (2011) noted that abdominal aortic aneurysm (AAA) repairs, both elective and rupture, are associated with significant blood loss often requiring transfusion.  Cell-salvage autotransfusion has been developed to reduce the need for allogeneic blood.  These investigators reviewed the literature to delineate the role of cell salvage in reducing allogeneic blood use in open AAA repairs.  A systematic search of the English-language literature was performed using the PubMed, Embase and Cochrane databases up to August 2010.  A total of 23 studies were identified.  While some data are conflicting, cell salvage appears to reduce overall use and exposure to allogeneic blood, and reduces length of intensive care unit and hospital stay after elective AAA repairs.  There may be additional benefit by combining cell salvage with other blood-conservation techniques.  Use of cell salvage in ruptured AAA repairs consistently reduced blood-product requirements.  The authors concluded that cell salvage appears to reduce blood-product use in both elective and rupture AAA repairs.  Moreover, they stated that owing to the heterogeneity in methodology of published data, further study may be needed before cell salvage becomes standard practice in open AAA repairs.

Tavare and Parvizi (2011) examined if the use of intraoperative cell-salvage (ICS) leads to negative outcomes in patients undergoing elective abdominal aortic surgery.  Altogether 305 papers were found using the reported search, of which 10 were judged to represent the best evidence to answer the clinical question.  The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated.  None of the 10 papers included in the analysis demonstrated that ICS use led to significantly higher incidence of cardiac or septic post-operative complications.  Similarly, length of intensive treatment unit (ITU) or hospital stay and mortality in elective abdominal aortic surgery were not adversely affected.  Indeed 2 trials actually show a significantly shorter hospital stay after ICS use, one a shorter ITU stay and another suggests lower rates of chest sepsis.  Based on these papers, the authors concluded that the use of ICS does not cause increased morbidity or mortality when compared to standard practice of transfusion of allogenic blood, and may actually improve some clinical outcomes.  As abdominal aortic surgery inevitably causes significant intra-operative blood loss, in the range of 661 to 3,755 ml as described in the papers detailed in this review, ICS is a useful and safe strategy to minimize use of allogenic blood.