Reimbursement may be made for the home use of an artificial kidney (dialysis equipment) (E1500-E1699) when such equipment is required by the patient because of end-stage renal disease (585.6). Claims submitted for these devices for other conditions will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

All equipment, supplies and support services, and certain drugs and biologicals which are required to effectively perform dialysis are covered as durable medical equipment (DME). This includes instruments and non-medical supplies [e.g., scales (E1639), stop watches, stethoscope, heating pad (E0210) for peritoneal dialysis, etc.] and disposable supplies [e.g., alcohol wipes (A4245), sterile drapes, etc.]. Standard or automatic blood pressure apparatus (A4660-A4670) are eligible only when used for end-stage renal disease (585.6). Claims submitted for these devices for other conditions will be rejected as not covered.

NOTE:

See Medical Policy Bulletin E-1 for guidelines on Thermometers.

These instruments and non-medical supplies must either be purchased or provided as part of the actual dialysis equipment and included in the overall charge for such equipment. (Coverage does not extend to the rental of these items separately. Therefore, claims for rental of these instruments/non-medical equipment should be denied. Disposable supplies are covered as separate items.)

Shipping charges for home dialysis supplies are covered. Installation and repairs of dialysis equipment may be paid regardless of whether the equipment is being rented or is purchased.

Some suppliers provide dialysis supplies in kits, for which a single charge is billed. Reasonable charge for the kits should be based on the lower of the kit prices or the total of the reasonable charges of all items in the kit.

An adjustable chair for ESRD patients (E1570) is covered when a component of a home dialysis delivery station. These chairs serve a therapeutic function of facilitating rapid changes in body position when acute hypotension occurs during dialysis. Since the cost of chairs may include a premium for style, or for the capacity to rock, swivel, heat, or vibrate, etc., claims for this item should be reviewed to assure that payment is consistent with what is reasonable and medically necessary to serve the intended therapeutic purpose.

Activated carbon filters for dialysis (A4680) are covered if used as a component of water purification systems to remove unsafe concentrations of chlorine and chloramines, when prescribed by a physician.

At the present time, there are two types of water purification systems which satisfy coverage requirements, deionization and reverse osmosis. When used in conjunction with a home hemodialysis unit (artificial kidney), either type of water purification system is covered.

The Ultrafiltration Monitor (S9007) is designed to reduce the clinical risks of over-filtration (the removal of too much fluid from body tissues) and underfiltration (the removal of too little fluid) during hemodialysis for end stage renal disease (ESRD)(585.6). The monitor is used to calculate fluid rates for patients who present difficult fluid management problems.

The Ultrafiltration Monitor is not medically necessary when ultrafiltration is performed independent of conventional dialysis. Therefore, it should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

The Sterile Connection Device (SCD) is an appropriate means of treatment for home continuous ambulatory peritoneal dialysis (CAPD) patients who are experiencing frequent infections at the connection site of the bag to the catheter. Intraluminal infection as a cause of peritonitis in CAPD is minimized to a certain extent by the proper use of SCD as compared to other methods. Therefore, SCD is covered when used in the treatment of CAPD patients.

The Ultraviolet Germicidal System (UVGS) is a connecting device which is used to ensure sterile technique for CAPD patients. The system includes the actual device, transfer set, clamp outlet port, and slide shield collar. Coverage for the UVGS is not limited to patients with a history of frequent infections or other disabilities.

The Trav-X-Change connection device is used for CAPD patients who require assistance with this technique. The device is recommended for use by patients with certain disabilities, such as poor vision or impaired manual dexterity, to aid them in performing CAPD. Payment for the Trav-X-Change device may be made only after it has been determined that use of the device is appropriate for the particular medical circumstance.

NOTE:

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 neither reasonable nor necessary for home dialysis patients and are not covered as durable medical equipment.

Also excluded from coverage is the Peridex Filter Set (A4913). This device has not been shown to be a medically necessary part of home dialysis. Therefore, it should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Shipping charges should be combined with the charge for the equipment.

The following items are not covered under the Federal Employee Program:

A4660-Sphygmomanometer/blood pressure apparatus with cuff and stethoscope
A4663-Blood pressure cuff only
A4670-Automatic Blood Pressure Monitor

Non-medical supplies for dialysis [i.e., scale (E1639), scissors, stopwatch, heating pad (E0210) for peritoneal dialysis, etc.]

MCIM 4270-4272.4, 5100.1

MCIM 55-2, 55-3