CurrentKaiser PermanentePolicy N/A

Clinical Review Criteria Dialysis Services

Clinical review criteria governing coverage and medical necessity determinations for standard hemodialysis, frequent/home dialysis (nocturnal or short-daily), home dialysis programs, and therapeutic ultrafiltration for congestive heart failure for Kaiser Foundation Health Plan of Washington members and providers.

Policy Summary

PayerKaiser Permanente

PolicyClinical Review Criteria Dialysis Services

Policy CodePolicy N/A

Change TypeOperational and content updates (codes merged/added)

Effective DateN/A

Next Review DateN/A

Key ActionVerify authorization requirements for specific codes by plan type using the Pre-authorization Code Check.

SourceLink

POLICY UPDATE CHANGES

Merged 'Ultrafiltration for the Treatment of Congestive Heart Failure' criteria and retitled to Dialysis Services.

Added and updated applicable CPT/HCPCS codes including 90999 and 99512 and new codes released 01/01/22 and 04/01/22.

3x/weekStandard hemodialysis frequency considered standard of care

>3x/weekFrequent hemodialysis stance

insufficient evidenceUltrafiltration for CHF stance

2008-2026Document history (selected years)

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Coverage and Medical Necessity Criteria

Standard Hemodialysis (3x/week)

Covered when ALL of the following are met:

Standard hemodialysis criteria: Standard hemodialysis 3 days a week is covered for members with end stage renal disease.

Applies to in-center and home when appropriate; see applicable codes for billing guidance.

Frequent (Nocturnal or Short-Daily) Hemodialysis (In Home or Facility)

Frequent (Greater Than 3 Days a Week) Hemodialysis — stance

Frequent hemodialysis stance: There is insufficient evidence in the published medical literature to show that frequent (greater than 3 days/week) nocturnal or short-daily hemodialysis is as safe as standard services and/or provides better long-term outcomes than current standard therapies.

Considered Not Medically Necessary for Non-Medicare members; evidence was judged insufficient in multiple MTAC reviews.

Ultrafiltration for Treatment of Congestive Heart Failure

Therapeutic Ultrafiltration for Congestive Heart Failure — stance

UF for CHF stance: There is insufficient evidence to determine the efficacy and long-term safety of ultrafiltration versus standard care in acute decompensated heart failure; ultrafiltration does not meet MTAC criteria and is not supported as first-line therapy.

Medicare: may be considered medically necessary when applicable criteria are met; Non-Medicare: considered not medically necessary (see applicable codes).

Home Dialysis Additional Criteria (Non-Medicare)

Home dialysis eligibility: Member is stable on dialysis; free of complications and significant concomitant disease that would render home dialysis unsuitable or unsafe; member or caregiver capable of completing home dialysis training and adhering to a prescribed treatment regimen; adequate caregiver available during dialysis; back-up arrangements with a facility-based dialysis center are in place.

These additional criteria apply for home dialysis coverage decisions (Non-Medicare members).

For Non‑Medicare members, frequent hemodialysis regimens (defined as >3 sessions per week, including nocturnal or short‑daily schedules) and therapeutic ultrafiltration for congestive heart failure (CHF) are considered not medically necessary because the published evidence is insufficient to demonstrate safety or improved long‑term outcomes compared with standard therapies. Standard hemodialysis delivered three times per week remains the covered therapy for members with end‑stage renal disease when applicable criteria are met, and applicable CPT/HCPCS verification should be performed via the Pre‑authorization Code Check.

The policy’s evidentiary stance is based on MTAC reviews and trial data: available trials (for example, UNLOAD and CARRESS‑HF) do not provide conclusive, high‑quality evidence that more frequent home hemodialysis improves long‑term patient‑important outcomes versus standard thrice‑weekly dialysis, and ultrafiltration for acute decompensated heart failure has shown mixed results and potential harms (e.g., worsening renal function in CARRESS‑HF). Consequently, frequent home hemodialysis (nocturnal or short‑daily) and therapeutic ultrafiltration for CHF do not meet medical technology assessment criteria and are judged insufficient for routine coverage in Non‑Medicare plans.

Providers should therefore expect coverage determinations to reflect this insufficiency of evidence: ultrafiltration is not supported as first‑line therapy for acute decompensated heart failure with volume overload, and frequent (>3x/week) home hemodialysis is considered not medically necessary for Non‑Medicare members unless future high‑quality evidence demonstrates safety and superior outcomes. Verify code‑level authorization requirements using the Pre‑authorization Code Check before submitting requests.

Provider Requirements, Prior Authorization, and Denial Risks

Denial Risk

Denial risk for ultrafiltration (Non-Medicare) and preferred initial therapy for ADHF

Ultrafiltration for congestive heart failure (CHF) is not supported as first-line therapy by current MTAC evidence and may be denied for Non-Medicare members. Evidence (e.g., CARRESS-HF) shows stepped pharmacologic therapy (IV loop diuretics with adjunct distal-acting diuretics, vasodilators, inotropes as needed) is superior to ultrafiltration for many hospitalized ADHF patients and ultrafiltration does not meet Kaiser Permanente MTAC criteria.

Non-Medicare denial risk: Therapeutic ultrafiltration (e.g., CPT 0692T) is listed as Not Medically Necessary for Non-Medicare members.
Preferred initial therapy for ADHF: Stepped pharmacologic therapy (IV loop diuretics ± distal-acting diuretics, IV vasodilators, inotropes as clinically indicated) is favored over ultrafiltration based on available evidence.
Ongoing trials (e.g., AVOID-HF) may affect future determinations; current policy reflects insufficient evidence supporting ultrafiltration.

Documentation Required

Required documentation to support medical necessity

Submit documentation sufficient to demonstrate medical necessity. Incomplete documentation may delay or result in denial of prior authorization.

Required: Last 6 months of clinical notes from the requesting provider and/or specialist.
Include documentation of prior pharmacologic management for ADHF (dosing and response to IV loop diuretics and adjuncts) when ultrafiltration or alternative dialysis modalities are requested.
Provide relevant lab values, weight/volume status, urine output, and notes on renal function trends if requesting ultrafiltration for cardiorenal indications.

Denial Risk

Denial risk for frequent hemodialysis (Non-Medicare)

For Non‑Medicare members, frequent hemodialysis (>3 days/week), nocturnal or short daily schedules are considered Not Medically Necessary and may be denied.

Affected codes (examples listed elsewhere in policy): CPT 99512, CPT 90999 — verify specific code requirements via Pre-authorization Code Check.
Standard in‑center hemodialysis (three times per week) remains the covered standard when criteria are met; home dialysis has additional stability and training requirements.

Definitions and Modalities

Conventional hemodialysis (standard)

FrequencyThree sessions per week (3x/week)

Duration per sessionEach session typically lasts 3 to 5 hours

SettingPerformed in a dialysis center, hospital, or at home when appropriate

Nocturnal hemodialysis

Session lengthLonger sessions typically 6 to 8 hours performed overnight

Frequency rangeUsually 3 to 7 nights per week

SettingCan be performed at home or in a dialysis center

Short-daily hemodialysis

Session lengthShorter sessions typically about 1.5 to 3 hours

FrequencyPerformed 4 to 6 days per week (more frequent than standard)

SettingCan be performed at home or in a dialysis center

Therapeutic ultrafiltration (UF) for congestive heart failure

DefinitionExtracorporeal removal of fluid to treat volume overload in acute decompensated heart failure

Evidence summaryMTAC reviews conclude there is insufficient evidence to determine the efficacy and long-term safety of ultrafiltration versus standard care

Clinical implicationUltrafiltration is not supported as first-line therapy for ADHF and does not meet MTAC criteria

99512	Home visit for hemodialysis
90999	Unlisted dialysis procedure, inpatient or outpatient
E1629	Tablo hemodialysis system for the billable dialysis service

OpenPayer

Clinical Review Criteria Dialysis Services

Coverage and Medical Necessity Criteria

Applicable Codes and Billing

Provider Requirements, Prior Authorization, and Denial Risks

Background and Scope

Definitions and Modalities