Nonvalvular Atrial Fibrillation
Rivaroxaban* (Xarelto®), dabigatran* (Pradaxa®), apixaban* (Eliquis®), and edoxaban* (Savaysa®) may be considered medically necessary in adult patients 18 years of age or older with documented paroxysmal, persistent, or permanent atrial fibrillation (AF) not complicated by valvular disease, as an alternative to warfarin therapy
DVT/PE Prophylaxis for Patients Undergoing THR/TKR
Rivaroxaban* (Xarelto®), dabigatran (Pradaxa®), and apixaban* (Eliquis®) may be considered medically necessary for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism in adult patients 18 years of age or older who are undergoing knee or hip replacement surgery.
Edoxaban (Savaysa®) is considered investigational for this indication.
Treatment and Secondary Prevention of Acute DVT/PE
Rivaroxaban* (Xarelto®), dabigatran* (Pradaxa®), apixaban* (Eliquis®), and edoxaban* (Savaysa®) may be considered medically necessary for treatment of acute DVT or PE, including long-term treatment and secondary prevention of thromboembolism.
Other Indications
The use of rivaroxaban, dabigatran, and apixaban, and edoxaban is considered investigational for all other indications, including but not limited to:
1. Prophylaxis of DVT and PE in hospitalized medically ill patients
2. Secondary prevention of cardiovascular events after an ACS
3. Periprocedural anticoagulation for catheter ablation of atrial fibrillation
4. Electrical or pharmaceutical cardioversion of atrial fibrillation
* FDA-approved indication.
