Prior authorization required for HHD services

Prior authorization is required for home hemodialysis services billed under the listed codes and coverage is contingent on meeting the policy's medical necessity criteria (stability on dialysis, completion of training, well‑functioning vascular access, and absence of contraindicating comorbidities). Submit PA requests using the applicable procedure/service codes: 90963–90970, 90989, 90993, 99512, and S9335.

• Coverage contingent on meeting medical necessity criteria: stable on dialysis; training completed; absence of unsafe comorbidities; well‑functioning vascular access.
• Use the listed CPT/HCPCS codes when requesting prior authorization.

Justify HHD modality and device use in PA

When requesting prior authorization that involves a specific HHD device or modality (e.g., Tablo system), include clinical justification and device‑specific training/support plans; clinical trial and device study reports cited in the evidence assessment are limited by small samples and short durations and should not substitute for case‑specific justification.

• Include indication, device model or system, and a description of training and support for patient/caregiver.
• Reference relevant trial/device study outcomes only as supporting evidence, not sole justification.

PA depends on member's benefit plan

Prior authorization requirements and the application of this policy depend on the member's specific benefit plan; verify and follow the member‑specific benefit document (and applicable federal/state mandates) before requesting authorization. This policy may be applied to Medicare Advantage in the absence of NCD/LCD guidance, per MAO rules.

• Check the member‑specific benefit plan document; in the event of conflict, the member plan governs.
• For Medicare Advantage members, confirm whether NCD/LCD exist; absent such guidance, MAO-level determinations may apply.

No step therapy required by policy

No formal step therapy sequence is specified in this policy; modality selection is determined by the attending nephrologist based on patient capability, contraindications, and individualized clinical judgment.

• Document clinical rationale for choosing HHD versus in‑center modalities when relevant to coverage decisions.

Consider home dialysis as step from in‑center care

Consider home dialysis as a clinically appropriate step from in‑center care when supported by multidisciplinary care and documented clinical benefit; systematic reviews associated home dialysis and multidisciplinary interventions with lower mortality and hospitalizations in observational studies.

• When transitioning from in‑center to home dialysis, document multidisciplinary supports (training, nursing/care coordination) and rationale tied to patient outcomes.

No explicit step therapy rules in policy

This document does not establish explicit step therapy rules or mandatory prior in‑center trial requirements for HHD; absence of such rules means clinical selection remains individualized.

• If a plan sponsor imposes step requirements, follow the member‑specific benefit plan terms.

Required clinical documentation for PA

Provide clinical documentation that supports the member is stable on dialysis, has completed or is enrolled in a dialysis training program (report CPT 90989 for completed course or 90993 per training session if incomplete), has a well‑functioning vascular access, and—when applicable—justifies the need for staff‑assisted (skilled) home hemodialysis.

• Include completed training documentation (CPT 90989) or session records (CPT 90993).
• Document vascular access type and function and any reasons skilled care is required (inability of patient/caregiver to perform HHD).

Document patient characteristics and training

Document patient‑specific characteristics that influenced selection for HHD, including age, comorbidities, prior dialysis regimen, and demonstrated training capability, because many studies included younger or healthier participants and observational evidence is subject to selection bias.

• Record patient's age, comorbid conditions, prior in‑center dialysis experience, and caregiver availability/ability.
• Note any study limitations referenced when using literature to support the request.

Reference member‑specific benefit documents

When deciding coverage and preparing prior authorization documentation, reference the member‑specific benefit plan document and any applicable federal or state mandates; document which plan provisions or mandates were used in the decision.

• Specify the member plan name and relevant clauses relied upon in the PA submission.
• For Medicare Advantage members, note whether NCD/LCD exist or whether MAO rationale is being used.

Denial triggers if medical necessity not met

Claims or PA requests may be denied if the individual does not meet the medical necessity criteria for HHD—examples include being unstable on dialysis, requiring skilled interventions during treatments, lacking completed training or an available caregiver, having contraindicating comorbidities, or lacking a well‑functioning vascular access.

• Denials likely when documentation fails to show stability, training completion (or plan for training), adequate access, or absence of unsafe comorbidities.
• For staff‑assisted requests, justify why patient/caregiver cannot perform HHD and why leaving home is contraindicated.

Selection and documentation risks for HHD requests

Because observational studies may reflect selection of healthier or higher‑resource patients to HHD, failing to document clinical suitability and reasons for selecting HHD (versus patient preference alone) increases the risk of denial; include objective clinical measures and rationale to mitigate selection‑bias concerns.

• Provide objective measures (clinical stability, lab trends, access function) and explain why HHD is clinically appropriate for this patient.
• Avoid relying solely on cited cohort benefits without patient‑specific justification.

Member‑specific benefit plan governs coverage

Coverage determinations must follow the member‑specific benefit plan; if the member's plan terms conflict with this policy, the member‑specific benefit plan governs and failure to adhere to plan terms can lead to denial.

• Always verify and document the applicable member benefit provisions used to make the coverage determination.
• If uncertainty exists for Medicare Advantage members, document whether MAO rationale or NCD/LCD was applied.