ModifiedUnitedHealthcarePolicy CS057ID.B

Home Hemodialysis (for Idaho Only)

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Medical policy governing coverage and medical necessity criteria for home hemodialysis (with and without skilled care) for members of UnitedHealthcare Community Plan in Idaho, including Idaho Medicaid Plus plans.

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for Idaho Only)

Policy CodePolicy CS057ID.B

Change TypeCoverage criteria revisedCPT code removals

Effective DateAug 1, 2025

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionVerify current applicable procedure codes and prior authorization requirements before billing or submitting authorization requests.

SourceLink

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ModifiedUnitedHealthcarePolicy CS057ID.B

Home Hemodialysis (for Idaho Only)

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Sign up for UnitedHealthcare Policy CS057ID.B alerts

Get alerted when Policy CS057ID.B changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for Idaho Only)

Policy CodePolicy CS057ID.B

Change TypeCoverage criteria revisedCPT code removals

Effective DateAug 1, 2025

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionVerify current applicable procedure codes and prior authorization requirements before billing or submitting authorization requests.

SourceLink

POLICY UPDATE CHANGES

Updated coverage criteria for home hemodialysis without skilled care as an alternative to facility-based hemodialysis for treating individuals with end-stage renal disease.

Removed CPT codes 90963, 90964, 90965, 90967, 90968, and 90969 from applicable codes.

Updated Description of Services, Clinical Evidence, FDA, and References sections to reflect the most current information.

2delivery settings

Idahostate-specific

6CPT codes removed

08/01/2025policy effective

99.5%/98.3%Kt/V meeting target

Coverage Criteria for Home Hemodialysis

Home Hemodialysis Without Skilled Care

Covered when ALL of the following are met

HHD without skilled care - all criteria: Individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments; AND individual undergoing hemodialysis or non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; AND absence of complications and significant concomitant disease that would cause home hemodialysis to be unsafe or unsuitable; AND individual has well-functioning vascular access.

Home Hemodialysis With Skilled Care (Staff-Assisted)

Covered when ALL of the following are met

HHD with skilled care - all criteria: Individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue; AND individual undergoing hemodialysis or non-professional caregiver is not capable of performing home hemodialysis; AND individual has medical contraindications to leaving home for hemodialysis; AND individual has well-functioning vascular access; AND staff-assisted home hemodialysis protocols generally match those provided in the hemodialysis center (i.e., 3 times per week, 3-4-hour treatments), with the exact dialysis therapy determined on an individual basis by the attending nephrologist.

Evidence synthesis relevant to coverage

Summary of findings from randomized trials and systematic reviews relevant to coverage considerations

Frequent in-center HD (FHN Daily) benefits: Frequent in-center HD (six times/week) showed benefit for composite outcomes (death or change in left ventricular mass; death or change in physical health) at one year and improvements in LV mass, blood pressure control, and shorter recovery time; however, these benefits were accompanied by increased arteriovenous access interventions and intradialytic hypotension. Extended follow-up suggested reduced long-term mortality in the intervention group but interpretation limited by crossover and sample size constraints.

FHN Daily Trial: HR 0.61 and HR 0.70 for composites; extended-follow-up HR 0.54 for mortality.

Nocturnal frequent HD (FHN Nocturnal) findings: Nocturnal home HD (six times/week) did not demonstrate significant benefit for the two co-primary outcomes at one year; extended follow-up analyses suggested higher mortality in the nocturnal arm in some analyses and increased vascular access events and accelerated loss of residual renal function. Findings are limited by small sample size, high crossover, and changes in prescriptions after trial end.

Interpret cautiously due to small sample size and treatment cross-over.

More frequent or longer HD overall evidence:

Home hemodialysis coverage (summary criteria)

Covered when ALL of the following are met

General

Vascular access: Individual has well-functioning vascular access.
Wording revised from 'presence of well-functioning vascular access' to 'individual has well-functioning vascular access'.
Dialysis adequacy: For thrice-weekly in-center equivalence, target single-pool Kt/V (spKt/V) of 1.4 per session with a minimum delivered spKt/V of 1.2 applies; adjustments may be made for residual kidney function.spKt/V >= 1.2 delivered (target 1.4)
Per NKF/KDOQI 2015 guidance.

Supporting considerations: Training completion, demonstration of caregiver capability where applicable, and documentation of delivered dialysis dose and monitoring for vascular access complications are expected as part of clinical documentation and prior authorization processes.

Home hemodialysis (HHD) coverage requires absence of conditions that would make treatment unsafe in the home setting. The policy requires that the individual is stable on dialysis, that there is no evidence skilled care interventions are necessary during treatments, that the individual or non‑professional caregiver has completed comprehensive training and can perform and maintain HHD, and that there is an absence of complications or significant concomitant disease that would render HHD unsuitable. These elements function as practical exclusions: when any of these conditions are not met, HHD without skilled care is not supported.

Follow-up from the FHN Nocturnal trial raised safety concerns: participants randomized to nocturnal frequent home HD had higher observed mortality in extended follow-up analyses and experienced more vascular access interventions and accelerated loss of residual renal function. These trial results were interpreted cautiously because of small sample size and treatment cross‑over, but they support caution in broadly applying nocturnal frequent HHD without careful patient selection and monitoring.

Available evidence for home long or frequent HD is inconclusive. Guideline groups and systematic reviews note the lack of randomized trials of home short frequent HD and conclude that, because data are limited and show potential harms (for example, increased vascular access procedures), no firm recommendations can be made for routine use of home long frequent regimens. Providers should therefore consider uncertain benefit, increased access risk, and individual patient characteristics when evaluating home long or frequent HD.

Home hemodialysis is not supported when the individual is unstable on dialysis, requires skilled interventions during treatments, or when adequate training or caregiver capability is lacking. The policy also requires a well‑functioning vascular access; absence of such access, or presence of significant comorbidities or complications that make home care unsafe, are scenarios in which HHD (without skilled care) would be inappropriate and may lead to denial.

There is no definitive high‑quality evidence that initiating more frequent (>3×/week) or extended‑length hemodialysis improves clinical outcomes across unselected adults with advanced CKD. Systematic reviews conclude that while some physiologic or symptom measures may improve in selected populations, the overall evidence is low to very low quality and does not establish broad outcome benefit sufficient to recommend intensive regimens for all patients.

Clinical trial and systematic review data indicate that more than thrice‑weekly or extended‑length HD during relatively short follow‑up did not improve key clinical outcomes and was associated with a greater number of vascular access procedures. These findings highlight increased procedural harms without clear mortality benefit in the short term.

Procedure and Billing Codes

Referenced Procedure/CPT and HCPCS Codesmixed

90966	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older.
90970	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older.
90989	Dialysis training, patient, including helper where applicable, any mode, completed course.
90993	Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session.
99512	Home visit for hemodialysis.
S9335	Home therapy, hemodialysis; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately), per diem.

Removed CPT CodesCPTNot Covered

90963	CPT code removed (previously applicable)
90964	CPT code removed (previously applicable)
90965	CPT code removed (previously applicable)
90967	CPT code removed (previously applicable)
90968	CPT code removed (previously applicable)
90969	CPT code removed (previously applicable)

spKt/V target — dialysis adequacy targets

Recommended target per thrice-weekly HDTarget single-pool Kt/V (spKt/V) of 1.4 per hemodialysis session

Minimum delivered doseMinimum delivered spKt/V of 1.2

Adjustment for residual kidney functionDose may be reduced in patients with significant residual native kidney function (Kru) provided Kru is measured periodically

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization: Delivered Dose and Safety Monitoring

Prior authorization is required and must include documentation of the delivered dialysis dose and device-specific safety monitoring data. Provide objective efficacy and safety endpoints from the home hemodialysis trial or program used (for example, weekly standard Kt/Vurea, delivered ultrafiltration compared to prescribed UF, and description of any prespecified adverse events and relatedness). Include evidence that the individual met trial endpoints or monitoring thresholds used to assess device or regimen performance.

Document weekly standard Kt/Vurea (e.g., target ≥ 2.1 when applicable) and/or per-protocol efficacy metric used by the device or program
Report UF delivery accuracy (e.g., achieved UF within ±10% of prescribed UF) and frequency of missed/partial UF deliveries
List prespecified adverse events observed during home treatments and note any events attributed to the device or home setting, with severity and outcome details
Include training completion documentation (CPT 90989 or 90993 where applicable), patient/caregiver competency assessments, and note if home visit (CPT 99512) or home therapy per-diem (S9335) services are used

Background and Rationale

Hemodialysis is a form of renal replacement therapy in which blood is circulated extracorporeally through a dialyzer to remove fluid and waste products by ultrafiltration and diffusion. Conventional in‑center HD is typically delivered three times per week for approximately 3–4+ hours per session; home hemodialysis uses dialysis systems designed for home use to allow flexible scheduling and delivery of equivalent therapy when the individual meets training, safety, and access requirements.

Definitions

Home hemodialysis (HHD) — definition and characteristics

DefinitionHemodialysis performed in the patient’s home using systems similar to in-center machines but designed for home use, allowing flexible scheduling and user-friendly safety features

Setting and flexibilityTreatments conducted at home and scheduled around the individual’s daily activities rather than dialysis center time slots

Equipment characteristicsHome HHD systems are user-friendly and possess numerous safety features to minimize complications

Candidate featuresSuitable individuals are motivated, stable on dialysis, free of significant comorbidity, have functioning vascular access, and have adequate space/caregiver support

Vascular access — definition and examples

Definition

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for Idaho Only)

Policy CodePolicy CS057ID.B

Change TypeCoverage criteria revisedCPT code removals

Effective DateAug 1, 2025

Last ReviewAug 1, 2025

Next Review DateN/A

Key ActionVerify current applicable procedure codes and prior authorization requirements before billing or submitting authorization requests.

SourceLink

On This Page

Systematic reviews found that more than thrice-weekly or extended-length HD did not improve clinical outcomes during short follow-up and was associated with a greater number of vascular access procedures (very low-quality evidence); overall quality of evidence for mortality and many clinical endpoints was low to very low, limiting definitive conclusions.

Studies often underpowered for mortality and enrolled younger/healthier populations than typical U.S. HD patients.

Home HD comparative outcomes: Observational cohorts and systematic reviews report that HHD is associated in some analyses with improved survival, better blood pressure control, and favorable quality-of-life trends compared with in-center HD; however, these findings are limited by nonrandomized designs and potential selection bias.

Examples include systematic reviews and registry/matched cohort analyses showing improved outcomes for selected HHD patients.

See policy for examples of training CPT codes and prior authorization code references.

Billing Rule

Verify Applicable Codes and Prior Authorization

Reviewers and providers must verify that the codes submitted match current payer requirements and that removed CPT codes are not used. If coverage criteria are not met or required monitoring/documentation is absent, prior authorization may be denied and claims may be subject to coding/billing risk.

Do not submit removed CPT codes (see Policy History for removed codes such as 90963–90969)
Confirm use of applicable ESRD/monthly or per-diem codes (e.g., 90966, 90970) and training codes (90989, 90993) as appropriate
Ensure prior authorization request references the clinical documentation of delivered dose and safety monitoring

Documentation Required

Required Clinical Documentation and Denial Triggers

Provide required clinical documentation demonstrating suitability for home hemodialysis and safety of the proposed therapy. Required materials should show stability on dialysis, completion of training, caregiver capability when applicable, and device-specific monitoring results. Lack of these documents is a common trigger for denial.

Evidence of stability on dialysis without need for skilled interventions during treatments
Training completion record (CPT 90989 for completed course or 90993 per session if course not completed) and competency assessment of patient and caregiver
Clinical notes addressing absence of contraindicating comorbidities and confirming well-functioning vascular access
Device- or program-specific monitoring logs (Kt/V, UF delivery, adverse events) used to support safety and efficacy

Note