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Home > Clinical Policy Bulletins > Medical > Coumadin (Warfarin) To Heparin Conversion Before And After Elective Surgery
Clinical Policy Bulletins
Number: 0200
(Updated)
Subject: Coumadin (Warfarin) To Heparin Conversion Before And After Elective Surgery
Reviewed: April 15, 2005
Important Note
This Clinical Policy Bulletin expresses Aetna's determination of whether certain services or supplies are medically necessary, experimental and investigational, or cosmetic. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in this Bulletin. The discussion, analysis, conclusions and positions reflected in this Bulletin, including any reference to a specific provider, product, process or service by name, trademark, manufacturer, constitute Aetna's opinion and are made without any intent to defame. Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information including correction of any factual error. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member's plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. CMS's Coverage Issues Manual can be found on the following website:
http://cms.hhs.gov/manuals/pub06pdf/pub06pdf.asp.
Policy
Aetna considers continuous intravenous heparin infusion medically necessary for members taking oral anticoagulants (warfarin) who require the maintenance of anticoagulation prior to and after diagnostic or therapeutic procedures. For most members, pre-procedure weaning of the oral anticoagulant may be safely accomplished on an outpatient basis. When circumstances arise that might compromise the member's state of anticoagulation such that thrombotic complications may occur, up to three inpatient pre-procedure days may be considered medically necessary.
See also CPB 255 - Inpatient Admission Prior to Surgery (Preop Days), CPB 346 - Low-Molecular-Weight Heparins, and CPB 463 - Home Treatment of Deep Venous Thrombosis.
Background
The most common indications for warfarin therapy are atrial fibrillation, the presence of a mechanical heart valve, prior thromboembolism, a documented left ventricular thrombus or a history of venous thromboembolism with or without a pulmonary embolism.
Patients receiving long-term warfarin therapy may present a problem if they require surgery because the interruption of anticoagulant therapy increases their risk of thromboembolism. Rational decisions regarding the appropriateness of peri-operative anticoagulation depends on individual patient factors and can only be made when the risk of peri-operative thromboembolism is balanced against the risk of peri-operative bleeding.
After warfarin therapy is discontinued, it generally takes several days for its anti-thrombotic effect to recede. Most invasive procedures can be performed safely when the international normalized ratio (INR) is less than 1.5.
Pre-procedure Regimen:
The treating physician should determine the INR targets required for best protection against thromboembolism while minimizing the risk of bleeding for the planned procedure. For most patients, the literature indicates that warfarin therapy may be discontinued 3-4 days prior to the date of the planned elective surgery to allow the INR to fall spontaneously. On the second day after discontinuing warfarin, the INR may be checked as an outpatient and when the anti-thrombotic threshold value is reached, the patient may be admitted to the hospital for continuous intravenous heparin infusion. In most cases, this occurs on the day before or the day of the planned procedure.
Post-procedure Regimen:
When the physician decides to restart oral anticoagulation after the procedure, an effort should be made to time the discontinuance of intravenous heparin with the establishment of adequate anti-thrombotic protection in the inpatient setting. The literature indicates that conversion back to pre-procedure levels of oral anticoagulation can also be bridged by using subcutaneous injections of low molecular weight heparin in the home setting after discharge.
ICD-9 Codes
ICD-9 Codes:
427.31 Atrial fibrillation
444 - 444.9 Arterial embolism and thrombosis
451.1 Phlebitis and thrombophlebitis of deep vessels of lower extremities
451.81 Phlebitis and thrombophlebitis of iliac vein
453.2 Venous embolism and thrombosis of vena cava
V43.3 Heart valve replacement
Revision Dates
Original policy: February 19, 1998
Updated: October 8, 2002; June 24, 2003; April 23, 2004; April 15, 2005
Revised: May 4, 2001; January 8, 2002
The above policy is based on the following references:
Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med. 1997;336(21):1506-1511.
Borman RJ, Danby D, Turner RC. Management of the anticoagulated patient for elective surgery. J Foot Surg. 1991;30(3):308-309.
McCormack P, Simcock PR, Tullo AB. Management of the anticoagulated patient for ophthalmic surgery. Eye. 1993;7(Pt 6):749-750.
Encke A. Surgery in patients treated with anticoagulation during emergency and elective interventions. Chirurg. 1997;68(7):670-674.
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Katholi RE, Nolan SP, McGuire LB. The management of anticoagulation during noncardiac operations in patients with prosthetic heart valves. Am Heart J. 1978;96(2):163-165.
Tavel ME, Stein PD. Management of anticoagulants in a patient requiring major surgery. Chest. 1998;114(6):1756-1758.
Schreiber R. Regarding clinical practice guidelines on the use of warfarin. J Am Geriatr Soc. 2001;49(1):96-97.
Sebastian JL, Tresch DD. Use of oral anticoagulants in older patients. Drugs Aging. 2000;16(6):409-435.
Douketis JD, Crowther MA, Cherian SS. Perioperative anticoagulation in patients with chronic atrial fibrillation who are undergoing elective surgery: Results of a physician survey. Can J Cardiol. 2000;16(3):326-330.
Douketis JD, Crowther MA, Cherian SS, et al. Physician preferences for perioperative anticoagulation in patients with a mechanical heart valve who are undergoing elective noncardiac surgery. Chest. 1999;116(5):1240-1246.
Hewitt RL, Chun KL, Flint LM. Current clinical concepts in perioperative anticoagulation. Am Surg. 1999;65(3):270-273.
Rauck RL. The anticoagulated patient. Reg Anesth. 1996;21(6 Suppl):51-56.
Hirsh J, Anand SS, Halperin JL, et al. Guide to anticoagulant therapy: Heparin: A statement for healthcare professionals from the American Heart Association. Circulation. 2001;103(24):2994-3018.
Ansell J, Hirsh J, Dalen J, et al. Managing oral anticoagulant therapy. Chest. 2001;119:22S-38S. Available at:
http://www.chestjournal.org/cgi/content/full/119/1_suppl/22S. Accessed September 11, 2002.
Watts SA, Gibbs NM. Outpatient management of the chronically anticoagulated patient for elective surgery. Anaesth Intensive Care. 2003;31(2):145-154.
Jafri SM. Periprocedural thromboprophylaxis in patients receiving chronic anticoagulation therapy. Am Heart J. 2004;147(1):3-15.
Property of Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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