Ultrafiltration in Decompensated Heart Failure (ARCHIVED)

Policy ID: S-192-020

Section: Surgery

Effective Date: January 04, 2021

Revised Date: March 07, 2024

Revision Effective Date: May 06, 2024

Last Reviewed: March 19, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective May 06, 2024. Click the Archive tab above for more information.

Policy ID: S-192-020

Section: Surgery

Effective Date: January 04, 2021

Revised Date: April 15, 2021

Revision Effective Date: July 05, 2021

Last Reviewed: July 26, 2023

Archived Date: May 06, 2024

Applies To: Commercial and Medicaid Expansion

Description

Ultrafiltration is designed to remove excess salt and water from the body safely, predictably, and effectively from individuals with decompensated heart failure and suffering from fluid overload.

Note: This policy does not apply to individuals with renal failure being treated using dialysis.

Criteria

The use of ultrafiltration for acute decompensated heart failure may be considered medically necessary when ALL the following criteria are met:

Individual has fluid volume overload; and
Individual has dyspnea at rest or with minimal activity; and
Individual has confirmed diuretic resistance defined as:
- Dose escalation beyond previously recognized dose ceiling; or
- Daily dose maximum is being reached without incremental improvement in diuresis.

The use of ultrafiltration not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.

Procedure Codes

37799

Diagnosis Codes

Covered Diagnosis Codes

I50.20

I50.21

I50.23

I50.30

I50.31

I50.33

I50.40

I50.41

I50.43

I50.810

I50.811

I50.813

I50.814

I50.82

I50.83

I50.89

I50.9

Professional Statements and Societal Positions Guidelines

American College of Cardiology Foundation and American Heart Association-2017

The American College of Cardiology Foundation and American Heart Association published joint guidelines (2013) on the diagnosis and management of heart failure in adults (under Recommendations for Hospitalized Individual) that list ultrafiltration as a class IIb recommendation (benefit greater than or equal to risk, additional studies needed). The recommendations indicated that ultrafiltration "may be considered for individuals with obvious volume overload to alleviate congestive symptoms and fluid weight" (level of evidence B: conflicting evidence) and "for individuals with refractory congestion not responding to medical therapy" (level of evidence C: recommendation less well established). A 2017 update from the American College of Cardiology, the American heart Association Task Force on Clinical Practice Guidelines, and the Heart Failure Society of America did not mention ultrafiltration.

ND Committee Review

Internal Medical Policy Committee 11-19-2020 New Policy

Internal Medical Policy Committee 5-20-2021 Revision:

Change in Title (removed Aquapheresis Therapy);
Updated criteria
Added the following covered diagnosis codes:
- I50.20; I50.21; I50.23; I50.30; I50.31; I50.33; I50.40; I50.41; I50.43; I50.811; I50.813; I50.814; I50.82; I50.83; I50.89; and I50.9

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria.

Internal Medical Policy Committee 7-21-2022 Annual Review - no changes in criteria

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

Internal Medical Policy Committee 3-16-2024 Archived policy - Effective May 06, 2024

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.

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