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Home Dialysis Equipment and Supplies

Section: Durable Medical Equipment
Effective Date: October 31, 2019
Revised Date: October 13, 2019
Last Reviewed: September 26, 2019

Home dialysis equipment is all equipment, supplies and support services, and certain drugs and biologicals which 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.]

Policy Position

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 will be 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

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 patients in correcting alarm conditions. These devices are considered not medically necessary.

Diagnosis Codes

N18.6

Links