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Dialysis services (acute and chronic hemodialysis and peritoneal dialysis)
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Defines coverage and limitations for acute and chronic dialysis services and supplies (peritoneal and hemodialysis) for UnitedHealthcare West members, including authorization and network requirements.
Routine review; no change to coverage guidelines.
Coverage Criteria for Dialysis Services
Covered Benefits — Acute and Chronic Dialysis
Covered when ALL of the following are met
Benefits limited to equipment/supplies meeting member needs and plan specifications.
Being outside the geographic area does not entitle the member to coverage for maintenance of chronic dialysis to facilitate travel.
The following services are not covered: travel dialysis and non-emergent out-of-area dialysis services. These items are excluded from benefits and will be denied when billed as maintenance or elective dialysis provided to facilitate travel or when received outside the member’s network for non-emergent reasons.
Provider Requirements and Authorization
Prior Authorization Required
Acute and chronic dialysis (peritoneal or hemodialysis) services and supplies require authorization. Authorization must be obtained from the member's network medical group or UnitedHealthcare. Dialysis must be provided within the member's network medical group when required by the plan. Members outside the geographic area served by the network medical group are not entitled to coverage for maintenance chronic dialysis solely to facilitate travel.
- Applies to acute and chronic dialysis (peritoneal and hemodialysis)
- Authorization source: member's network medical group or UnitedHealthcare
Home Hemodialysis Prior Criteria
For home hemodialysis, coverage is subject to the criteria specified in the separate Medical Policy titled "Home Hemodialysis." Providers must follow the prior criteria and documentation requirements in that policy before coverage will be authorized.
- See Medical Policy: Home Hemodialysis for required criteria prior to coverage
- Benefits limited to equipment/supplies that meet minimum specifications
Medical Necessity and Authorization
All services must be medically necessary and are subject to the member's Evidence of Coverage/Schedule of Benefits. When there is a discrepancy between this policy and the member's EOC/SOB, the EOC/SOB governs. Acute and chronic services require authorization as applicable.
- Medical necessity required for all services
- Follow member's EOC/SOB for plan-specific provisions
Network/Location-based Denial Risk
Maintenance chronic dialysis provided outside the member's network medical group or non-emergent out-of-area dialysis (including travel dialysis) is not covered and may be denied.
- Travel dialysis and non-emergent out-of-area dialysis services are not covered
- Providing maintenance chronic dialysis outside the network medical group risks noncoverage/denial
Background
Dialysis provides renal replacement therapy for both acute and chronic kidney failure and includes two primary modalities: hemodialysis and peritoneal dialysis. Coverage in this policy applies to both acute and chronic dialysis services and related supplies when medical necessity, authorization, and network requirements are met. Home hemodialysis is a distinct modality with its own required criteria and prior authorization rules; refer to the separate Home Hemodialysis medical policy for coverage requirements specific to home hemodialysis.
Definitions
Revision History and Policy Changes
Policy effective date updated to January 1, 2026; previous policy version BIP044.N archived.
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