Home Dialysis Equipment and Supplies

Policy ID: E-2-031

Section: Durable Medical Equipment

Effective Date: November 01, 2019

Revised Date: July 01, 2022

Revision Effective Date: September 05, 2022

Last Reviewed: July 26, 2023

Applies To: Commercial and Medicaid Expansion

Description

Home dialysis equipment is all equipment, supplies and support services, and certain drugs and biologicals that are required to effectively perform dialysis in the home. This includes instruments and non-medical supplies [e.g., scales, blood pressure cuffs, stop watches, stethoscope, heating pad for peritoneal dialysis, etc.] and disposable supplies [e.g., alcohol wipes, sterile drapes, etc.]

Criteria

Home use of dialysis equipment, supplies, and selected medications may be considered medically necessary when the individual has a diagnosis of end-stage renal disease (ESRD).

All other uses of home dialysis equipment, supplies and selected medications not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

A4245

A4651

A4652

A4653

A4657

A4660

A4663

A4670

A4671

A4672

A4673

A4674

A4680

A4690

A4706

A4707

A4708

A4709

A4714

A4719

A4720

A4721

A4722

A4723

A4724

A4725

A4726

A4728

A4730

A4736

A4737

A4740

A4750

A4755

A4760

A4765

A4766

A4770

A4771

A4772

A4773

A4774

A4802

A4860

A4870

A4911

A4913

A4918

A4927

A4928

A4929

A4930

E0210

E1500

E1510

E1520

E1530

E1540

E1550

E1560

E1570

E1575

E1580

E1590

E1592

E1594

E1600

E1610

E1615

E1620

E1625

E1629

E1630

E1632

E1634

E1635

E1636

E1637

E1639

E1699

J1644

S9007

An exception to the general coverage of all dialysis supplies is the “Patient Aid,” a device used to train dialysis individuals in correcting alarm conditions. These devices are considered not medically necessary.

Shipping charges for home dialysis supplies are covered.

Diagnosis Codes

Covered Diagnosis Code

N18.6

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 New policy; updated language

Internal Medical Policy Committee 9-21-2020 Annual Review

Internal Medical Policy Committee 9-21-2021 updated language

Internal Medical Policy Committee 7-21-2022 Coding update - Effective September 05, 2022

Added Procedure code E1629

Internal Medical Policy Committee 7-26-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-2-030