Dialysis
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Defines Aetna's medical necessity, coverage, and coding stance for hemodialysis, home hemodialysis, and peritoneal dialysis services, equipment, and supplies for members with renal failure or end-stage renal disease.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical Necessity Criteria
Medically necessary when ALL of the following are met:
Aetna considers hemodialysis or intermittent PD necessary up to 3 times/week.
Conditions must be refractory to dialysis 3 times per week.
FDA-cleared portable/home systems (eg, NxStage System One, Tablo) are acceptable alternatives for home hemodialysis.
Medicare primary coverage of equipment typically begins after first 30 months; Aetna usually covers on a rental basis during the first 30 months.
Periodic skilled nursing monitoring per a physician-prepared care plan is included.
Evidence summaries and implied coverage considerations
Clinical context and evidence summaries relevant to coverage decisions for home hemodialysis, bioengineered access, combined RAAS blockade, and DCB angioplasty.
Supports limiting routine coverage to 3x/week unless documented indication present.
Randomized evidence limited; document prescription and operator competency.
Further RCTs needed to establish comparative benefit.
Balance potential mortality reduction against hypotension risk.
Coverage decisions may require case-specific rationale and prior authorization due to inconsistent RCT evidence.
Drug-coated balloon angioplasty — evidence summary
Coverage considerations for drug-coated balloon angioplasty:
Requests for DCB should include lesion-specific rationale and cited trial evidence given inconsistent benefit.
Bio-impedance monitoring (BCM) — evidence summary
Coverage considerations for multiple-frequency bio-impedance devices:
When billing for BCM, document device used, intermediate outcomes assessed, and clinical rationale due to limited evidence for hard outcomes.
PD peritonitis prevention — evidence summary
Coverage considerations for antimicrobial strategies to prevent PD peritonitis:
Document prior use of evidence-based perioperative strategies before considering alternative prophylactic approaches; evidence quality often low.
Nicotinic acid for hyperphosphatemia — evidence summary
Coverage considerations for nicotinic acid and related compounds for hyperphosphatemia:
If considered, monitor lipid profile and adverse events; evidence limited to small trials.
Peritoneal dialysis for heart failure — evidence summary
Coverage considerations for peritoneal dialysis in heart failure:
PD may be considered on case-by-case basis for diuretic-resistant HF but requires careful documentation of rationale and expected benefit.
Wearable hemodialysis devices — evidence summary
Coverage considerations for wearable hemodialysis devices:
Wearable devices (eg, listed HCPCS E1632/E1635) may be considered investigational or not covered depending on payer stance and code listings.
Vitamin E–coated membranes — evidence summary
Coverage considerations for vitamin E–coated membranes (ViE-m):
Documented biomarker improvements do not equate to proven clinical outcome benefit.
HIF-PHI agents — evidence summary
Coverage considerations for HIF-PHI agents in CKD anemia:
Coverage should consider regulatory status, agent-specific safety data, and need for monitoring (eg, iron parameters).
Evidence summaries — assorted meta-analyses and trial findings
Evidence-based conclusions and clinical considerations extracted from systematic reviews and meta-analyses:
Consider regulatory status and agent-level safety evidence when evaluating coverage.
IL-6 may be of prognostic interest but utility for guiding routine coverage decisions is limited.
Aetna does not consider backup equipment or precautionary spare supplies to be medically necessary when provided solely in anticipation of need for substitution or replacement. Specifically, spare deionizing tanks and similar precautionary items are not considered medically necessary. Emergency reserve supplies are an exception when provided at initiation of dialysis: up to a one-month supply as a one-time allowance is considered medically necessary to cover short-term increases in use or delivery delays. Also note that charges for repair and maintenance of rented equipment are included in rental fees and will be denied if billed separately.
Randomized trials and multicenter studies have not consistently demonstrated a patency advantage for drug-coated balloon (DCB) angioplasty versus conventional balloon angioplasty (CBA) for hemodialysis access stenosis. A pooled analysis of 11 RCTs (487 DCB, 489 CBA) found no statistically significant difference in 6- or 12-month target lesion primary patency, and multicenter trials cited in reviews also failed to show improved patency rates. Given these inconsistent results, the evidence does not establish routine superiority of DCB angioplasty for dialysis access and supports careful case-by-case consideration.
Guidance from the National Institute for Health and Care Excellence (NICE, 2017) concluded there is insufficient evidence to recommend routine adoption of the Body Composition Monitor (BCM) to guide fluid management in people with chronic kidney disease receiving dialysis. NICE also found inadequate validation or clinical-outcome data to support routine use of the InBody S10 or MultiScan 5000 for this purpose.
The provided document excerpts do not list explicit, universal coverage exclusions for several interventions; rather, they summarize uncertainty in benefits and note the need for higher-quality evidence. For example, systematic reviews of vitamin E–coated membranes and network meta-analyses of HIF-PHIs report mixed or incomplete evidence on hard clinical outcomes, but the text does not present a single blanket exclusion statement for these technologies in the excerpts shown.
Clinical Policy Bulletins are intended to assist in administering plan benefits but do not constitute offers of coverage or medical advice. This bulletin provides only a partial, general description of plan or program benefits and does not constitute a contract; it cannot guarantee coverage or specific clinical outcomes. Treating providers remain solely responsible for medical advice and treatment.
Peridex filter sets for peritoneal dialysis and certain precautionary ultrafiltration monitoring devices are considered not medically necessary when provided solely as spare or anticipatory equipment. The policy also states that short-wave diathermy machines are not covered for home use. Charges for repair of rented equipment are included in rental fees and will be denied if billed separately.
CPT / HCPCS / ICD-10 Coding
| 90935 | Hemodialysis procedure with single evaluation by a physician or other qualified health care professional. |
| 90937 | Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription. |
| 90999 | Unlisted dialysis procedure, inpatient or outpatient. |
| 99512 | Home visit for hemodialysis. |
| E1632 | Wearable artificial kidney, each. |
| E1629 | Tablo hemodialysis system for the billable dialysis service. |
| E1590 | Hemodialysis machine. |
| E1615 | Deionizer water purification system, for hemodialysis. |
| E1610 | Delivery and/or installation charges for hemodialysis equipment. |
| 90945 | Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation [CAPD, CCPD]. |
| 90947 | Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated physician evaluations, with or without substantial revision of dialysis prescription [CAPD, CCPD]. |
| 90999 | Unlisted dialysis procedure, inpatient or outpatient. |
| E1592 | Automatic intermittent peritoneal dialysis system. |
| E1594 | Cycler dialysis machine for peritoneal dialysis. |
| E1630 | Reciprocating peritoneal dialysis system. |
| A4680 | Activated carbon filters for hemodialysis, each. |
| A4690 | Dialyzer (artificial kidneys), all types, all sizes, for hemodialysis, each. |
| A4706 | Bicarbonate concentrate, solution, for hemodialysis, per gallon. |
| A4730 | Fistula cannulation set for hemodialysis, each. |
| A4720 | Dialysate solution, any concentration of dextrose, fluid volume greater than 249 cc but <=999 cc, for peritoneal dialysis. |
| N18.6 | End stage renal disease. |
| E87.5 | Hyperkalemia. |
| E83.39 | Other disorders of phosphorous metabolism [Hypophosphatemia]. |
| E87.70 | Fluid overload. |
| I50.1 | Heart failure. |
Provider Documentation, Prior Authorization, and Billing Guidance
Obtain prior authorization for dialysis services and equipment when selection criteria apply
Certain dialysis procedure and durable medical equipment CPT/HCPCS codes are listed as covered when Aetna selection criteria are met; providers should obtain prior authorization for services and equipment subject to coverage criteria (examples include 90935, 90937, 90945, 90947, 90999, and HCPCS such as E1590, E1610, E1615, E1629, E1632, S9335).
- Prior authorization recommended when coverage is contingent on selection criteria being satisfied.
- Covered codes include hemodialysis CPTs (90935, 90937, 90999), peritoneal dialysis CPTs (90945, 90947), and multiple HCPCS for equipment (E1590, E1610, E1615, E1629, E1632) and per-diem home therapy (S9335).
Document physician prescription, training, and indication for home or increased‑frequency dialysis
Prior authorization or documented justification may be required for home hemodialysis and for dialysis delivered more frequently than the standard thrice-weekly schedule; documentation must include the physician's prescription and evidence of training/competency of the person performing treatments.
- Physician prescription required for use of FDA-cleared home devices (eg, NxStage, Tablo) and for home treatments.
- Document that treatments are performed by a trained and qualified person deemed competent by the prescribing physician.
- When requesting >3 sessions/week, include clinical indication showing the condition is refractory to dialysis 3 times/week (eg, hyperkalemia, fluid overload, pregnancy, acute pericarditis, CHF, pulmonary edema, severe catabolic state).
Include indication and rationale for DCB angioplasty requests
Requests for drug‑coated balloon (DCB) angioplasty should include clinical indication and explicit rationale because randomized trials and multicenter data have not consistently shown improved patency versus conventional balloon angioplasty.
- Provide lesion‑specific rationale and citation of supporting evidence when seeking authorization for DCB angioplasty.
- Be aware that pooled RCT analyses (11 RCTs) did not show significant 6‑ or 12‑month primary patency benefit for DCB versus conventional balloon angioplasty.
No explicit PA rules in these excerpts — consult full policy
No explicit prior authorization requirements are specified in the cited excerpts; consult the full policy and plan documents for plan‑level prior authorization rules that may apply.
- The provided sections do not list additional PA rules or affected billing codes.
- Local plan contracts or benefit documents may impose separate PA requirements.
Consult full policy and plan documents for specific prior authorization requirements
Prior authorization rules are not fully enumerated in the partial bulletin; providers must consult the complete Clinical Policy Bulletin and member plan documents for specific prior authorization requirements.
- Clinical Policy Bulletins are a partial description of plan benefits and do not replace plan or contract language.
- Confirm PA requirements with the payer before delivering services when in doubt.
Operational guidance — CPB is administrative guidance, not a coverage contract
Operational note: Clinical Policy Bulletins are administrative guidance and do not constitute a contract; treating providers remain responsible for medical advice and treatment decisions.
- Use the CPB to inform benefit administration but verify coverage under the member's contract.
- Providers are independent and responsible for clinical care.
Justify escalation to >3 sessions/week with documented refractory indication
Escalation from standard thrice‑weekly dialysis to more frequent dialysis (>3x/week) requires documentation that the indicated refractory clinical condition is present and not controlled by dialysis three times per week.
- Allowed refractory indications include hyperkalemia, hypophosphatemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema, or severe catabolic state.
- Include objective documentation demonstrating failure of adequate control with 3x/week dialysis when requesting increased frequency.
Document prior use of evidence‑based PD peritonitis prevention strategies before advanced interventions
For prevention of PD peritonitis, document prior use of evidence‑based strategies (for example, peri‑operative IV vancomycin when indicated and antifungal prophylaxis after antibiotic use) before advancing to alternative or uncertain interventions.
- Document prior application of standard perioperative and topical measures and the outcomes.
- Record rationale for considering nasal antibiotic strategies given uncertain benefit in trials.
No step therapy algorithms provided in these excerpts
No step therapy algorithms are described in the provided excerpts.
- Providers should not assume formal step therapy sequences from these sections; verify with full policy if a step process exists.
Confirm coverage under the member's contract — CPB does not guarantee payment
Operational guidance from the CPB: participating providers are independent contractors; the bulletin assists benefit administration but does not guarantee coverage—confirm coverage under the member's contract.
- Clinical Policy Bulletins are not offers of coverage and do not constitute a contract.
- Absence of contractual language in the CPB may affect payment decisions under plan terms.
Ensure physician prescription and physician‑prepared care plan for home therapies and skilled nursing
For home therapies, the physician must prescribe treatment and a physician‑prepared care plan is required for skilled nursing monitoring; document the care plan and periodic physician review when billing for skilled nursing visits.
- Skilled nursing periodic monitoring must follow a care plan prepared and periodically reviewed by a physician.
- Physician prescription and documented care plan are required when billing home nursing or home hemodialysis services.
Document physician prescription and training/competency for home hemodialysis with FDA‑cleared devices
When prescribing home hemodialysis using FDA‑cleared home devices (eg, NxStage System One, Tablo), document the physician prescription and evidence of training/competency for the patient or caregiver.
- Treatments must be administered under a physician's prescription.
- Record that the person performing treatments is trained and deemed competent by the prescribing physician.
Document BCM device, intermediate outcomes, and rationale when billing for bio‑impedance monitoring
When billing for multiple‑frequency bio‑impedance monitoring (eg, BCM), document the device used, the intermediate outcomes assessed (such as over‑hydration measures and systolic blood pressure), and the clinical rationale given limited evidence for mortality benefit.
- Report device make/model (eg, BCM) and measurements before and after implementation.
- Record rationale for use and any changes to fluid management guided by BCM findings.
You may cite trial or meta‑analysis evidence to support clinical rationale (no specific citation format required)
Citation of trial or meta‑analysis evidence may be included to support clinical rationale for interventions with uncertain benefit, but the provided excerpts do not prescribe operational documentation requirements for such citations.
- Include relevant trial citations when justifying use of interventions with mixed evidence (eg, DCB angioplasty, ViE‑m, HIF‑PHIs).
- Evidence citation alone does not replace specific coverage/authorization requirements.
Providers remain responsible for clinical care; CPBs assist benefit administration
Treating providers remain responsible for medical advice and treatment decisions; Clinical Policy Bulletins assist in benefits administration but do not substitute for clinical judgment or create contractual coverage.
- Use CPBs to guide benefit interpretation but rely on clinical judgment for patient care.
- Confirm member coverage details separately from the CPB.
Do not bill separately for repair of rented equipment — repair charges are included in rental
Charges for repair or maintenance of rented equipment are included in rental fees; submit repair charges separately risks denial because such charges are considered part of rental.
- Do not bill separately for repair of rented dialysis equipment; those charges will be denied as included in rental charges.
- If member‑owned equipment is being repaired, rental of replacement equipment is considered medically necessary.
Frequency limits: >3x/week dialysis requires documented refractory indication to avoid denial
Dialysis delivered more than three times per week is considered medically necessary only for listed refractory conditions; requests for increased frequency without documentation of such indications may be subject to review or denial.
- Refractory indications include hyperkalemia, hypophosphatemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema, and severe catabolic state.
- Document that the condition is refractory to dialysis 3 times per week when requesting >3x/week treatments.
DCB angioplasty may be denied for lack of demonstrated patency benefit without strong case‑specific evidence
DCB angioplasty lacks consistent evidence of improved target‑lesion patency in pooled RCT analyses; requests solely to improve patency may be denied unless compelling, lesion‑specific evidence is provided.
- Meta‑analysis of 11 RCTs (487 DCB, 489 CBA) showed no significant difference in 6‑ or 12‑month primary patency.
- Multicenter trials have not consistently demonstrated patency benefits with DCB versus conventional angioplasty.
No further PA or denial triggers specified in these excerpts
No additional explicit prior authorization or billing denial triggers are identified in these specific excerpts; follow the PA/billing rules documented elsewhere in the full policy and payer guidelines.
- These sections do not describe further PA or denial triggers.
- Confirm local plan requirements for any additional triggers.
CPB statements are not guarantees of coverage — verify plan/contract language
Clinical Policy Bulletins provide partial benefit descriptions and do not guarantee coverage; absence of explicit coverage language in the CPB may lead to denial based on the member's contract terms.
- Verify coverage under the member's contract; CPBs are not contractual documents.
- Coverage decisions may depend on plan‑specific language beyond the CPB.
Policy Background and Scope
Hemodialysis or intermittent peritoneal dialysis is routinely provided up to 3 times per week for renal failure. Treatments performed more frequently than three times weekly may be considered medically necessary only when one or more refractory clinical conditions are present (for example, refractory hyperkalemia, refractory hypophosphatemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema, or severe catabolic state). Home hemodialysis using FDA-cleared portable systems (such as NxStage or Tablo) is accepted when prescribed by a physician and performed by trained, competent personnel with required documentation and care planning.
Key Definitions
Policy Dates and Revision History
Policy became effective.
Policy was last reviewed.
Next review scheduled.
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