CurrentCapital BluecrossPolicy MP 2.078

Ultrafiltration in decompensated heart failure

Defines medical necessity criteria for inpatient ultrafiltration (aquapheresis) for patients with decompensated heart failure and volume overload, lists applicable diagnosis and procedure codes, notes product/benefit variations and evidence summary.

Policy Summary

PayerCapital Bluecross

PolicyUltrafiltration in decompensated heart failure

Policy CodePolicy MP 2.078

Change TypeNo material change in current version (history includes prior major and administrative updates)

Effective DateApr 1, 2025

Next Review Date

Key ActionProvider must document fluid volume overload, dyspnea at rest or with minimal activity, and confirmed diuretic resistance to support medical necessity.

POLICY UPDATE CHANGES

Policy statement updated to state ultrafiltration may be considered medically necessary in the inpatient setting when specific criteria are met.

12/02/2021 code 0692T added to coding list.

11/12/2021 policy statement changed from 'investigation' to 'not medically necessary'.

11/13/2024 Retirement Review noted (consensus review prior to that with no change).

1Coverage stance for defined indication

Multiple RCTs/meta-analysesEvidence base

Higher adverse events in some RCTsSafety signal