Prior authorization: Percutaneous AVF creation (CPT 36836, 36837)

Percutaneous AVF creation CPT codes 36836 and 36837 are listed as covered with no prior authorization required; in addition, the policy states prior authorization is not required for dialysis for Priority Health Medicare members.

• 36836 — Percutaneous arteriovenous fistula creation, upper extremity, single access (Ellipsys) — no prior authorization required.
• 36837 — Percutaneous arteriovenous fistula creation, upper extremity, separate access sites (WavelinQ) — no prior authorization required.

ASC-billable dialysis circuit HCPCS codes may require facility/provider authorization

The policy identifies HCPCS codes C7513, C7514, C7515, and C7530 as dialysis-circuit intervention codes that are billable by ambulatory surgical centers (ASC) and may require standard facility/provider authorization per site-of-service rules.

• C7513 — Dialysis circuit introduction with angiography and central segment angioplasty (Billable by ASC).
• C7514 — Same as C7513 with central segment stent placement (Billable by ASC).
• C7515 — Dialysis circuit introduction with permanent endovascular embolization/occlusion (Billable by ASC).
• C7530 — Dialysis circuit introduction with peripheral and central angioplasty plus stent placement (Billable by ASC).

Home hemodialysis (HHD) — modality description (no step therapy specified)

Home hemodialysis (HHD) is described as a self-dialysis option performed at home on a more intensive schedule than conventional in‑center HD, intended to reduce morbidity and mortality by shortening the interdialytic interval.

• HHD involves patient self-dialysis several times per week at home, day or overnight, on a more intensive schedule than conventional in-center HD.
• No step therapy requirements are specified for HHD in this portion of the policy.

Clinical guideline references (no step therapy specified)

The document references clinical guidance sources (e.g., KDOQI, CMS manuals) to inform practice standards; the policy portion does not specify an explicit step therapy sequence.

• References include CMS Medicare Benefit Policy Manual Chapter 11 and KDOQI vascular access and nutrition guidelines.
• No stepwise treatment or prior-step requirements are defined in this section.

Document patient education and transplant referral for advanced CKD (eGFR <30)

Document patient education about dialysis modalities and evidence of transplant evaluation/referral when eGFR <30 mL/min/1.73 m2 or when preparing for dialysis initiation and access placement.

• Provide and document education on transplantation, peritoneal dialysis, home and in‑center hemodialysis, and conservative treatment per KDOQI guidance.
• Refer patients interested in transplantation with no contraindications to a transplant program when eGFR <30 mL/min/1.73 m2 and document evaluation steps taken.

Reporting and documentation: Condition Code 74 and appropriate ESRD/dialysis codes

When dialysis services occur in the home setting, report Condition Code 74 and include appropriate CPT/HCPCS codes for dialysis training, ESRD monthly/partial-month services, vascular access, and imaging/interventional procedures as documented in the policy.

• Condition Code 74 — Renal dialysis setting - home (report when applicable).
• Include relevant codes such as 90989 (partial-month ESRD), 90993/90989 (training), and vascular access/interventional codes as appropriate.

Prior authorization not required for Dialysis for Priority Health Medicare members

Prior authorization is not required for dialysis services for Priority Health Medicare members per the policy coding information.

• Providers delivering dialysis for Priority Health Medicare members do not need to obtain prior authorization.

Not covered devices — risk of denial for C8000, E1632, E1635

Use of the listed not‑covered devices (C8000, E1632, E1635) is identified as not covered and may lead to claim denial or nonpayment.

• C8000 — Support device, extravascular, for arteriovenous fistula — Not Covered.
• E1632 — Wearable artificial kidney — Not Covered.
• E1635 — Compact (portable) travel hemodialyzer system — Not Covered.