ModifiedUnitedHealthcarePolicy CS057NJ.L

Home Hemodialysis (for New Jersey Only)

This policy governs coverage and medical necessity criteria for home hemodialysis services in New Jersey, including both non‑skilled (patient/caregiver performed) and skilled (staff‑assisted) home hemodialysis for individuals with end‑stage renal disease.

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for New Jersey Only)

Policy CodePolicy CS057NJ.L

Change TypeCoverage criteria revisedcoding notation removed

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionVerify plan-specific code coverage and prior authorization rules and document stability, training, and presence of well-functioning vascular access when requesting home hemodialysis coverage.

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 notation indicating certain CPT codes are not on the State of New Jersey Medicaid Fee Schedule.

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

05/01/2025Policy revision date

1.4spKt/V target

349 v 1,047Ok et al. cohort (HHD vs in-center)

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Shah et al. USRDS cohort

Coverage and Medical Necessity Criteria

Medically Necessary Coverage Criteria

Home hemodialysis is medically necessary as an alternative to facility-based hemodialysis when ALL required criteria are met. Two parallel sets of criteria apply depending on whether treatment is performed by the patient/non‑professional caregiver (non‑skilled) or requires staff assistance (skilled).

Non‑skilled (patient or non‑professional caregiver performed) HHD

Individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments.
Individual undergoing hemodialysis or non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol.
Absence of complications and significant concomitant disease that would cause home hemodialysis to be unsafe or unsuitable.
Individual has well-functioning vascular access.

Skilled (staff‑assisted) HHD

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

Evidence summaries (no coverage decision provided)

Evidence-based findings summarized by study type and outcomes (inform clinical judgment but do not themselves determine coverage):

Observational cohorts: Multiple cohort studies report associations of HHD or intensive/extended HD with lower mortality and improved control of phosphate and blood pressure compared with in-center conventional HD or PD, but are limited by observational design and potential selection bias.

Example: Ok et al. 2023 (matched cohort: lower all-cause mortality, better phosphate/BP control).

Large registry analysis: USRDS-based cohort analyses describe demographic differences and adjusted mortality risks after starting HHD, with some sex and geographic associations noted.

Example: Shah et al. 2023 (42,849 patients).

Randomized trials (FHN Trials): FHN Daily Trial showed benefits for some composite endpoints and secondary measures (BP, LV mass reduction, shorter recovery time) but increased vascular access interventions; FHN Nocturnal Trial did not show benefit on co-primary outcomes and reported more adverse events and higher mortality in extended follow-up; trials limited by small sample sizes, crossover, and prescription changes.

Home Hemodialysis Coverage (summary)

High-level summary: home hemodialysis is covered when the policy’s coverage criteria are met; the policy was revised effective 05/01/2025 with clarifications to coverage language.

Home hemodialysis coverage conditions (summary): Policy updated to cover home hemodialysis without skilled care as an alternative to facility-based hemodialysis for treating individuals with end-stage renal disease; requires that the individual has well-functioning vascular access and meets other detailed criteria in the full policy.

Material revision effective 05/01/2025 replaced wording to specify that the individual has well-functioning vascular access and updated supporting sections; see full policy for the complete criteria set.

The policy does not enumerate a separate list of explicit exclusions. Instead, exclusions are implied as the inverse of the medical necessity criteria: services are covered only when all specified criteria for non‑skilled or skilled home hemodialysis are met. Therefore, individuals who are not stable on dialysis, who require skilled interventions during treatments, who lack the ability or a trained non‑professional caregiver to perform or maintain HHD, who have significant contraindicating comorbidities or complications, or who do not have well‑functioning vascular access would fall outside the coverage criteria.

Randomized trial data raise safety concerns for some intensive home regimens. The FHN Nocturnal trial reported accelerated loss of residual renal function, increased vascular access interventions, and a higher mortality rate in the nocturnal arm compared with conventional HD; investigators concluded these findings warrant further investigation. These trial-specific safety signals should be considered when evaluating candidates for longer or more frequent home HD schedules.

A prior notation that several CPT codes were not listed on the New Jersey Medicaid fee schedule has been removed from the policy. Providers should consult state‑specific fee schedules and contractual benefit terms to determine coverage and any plan-level exclusions for applicable home dialysis CPT/HCPCS codes.

Home hemodialysis is declared medically necessary only when all listed coverage criteria are met (see non‑skilled and skilled criteria). By construction, conditions or situations that fail to meet any required criterion imply the service is not covered under this medical necessity determination.

The excerpts provided do not include standalone, explicit statements labeled “not medically necessary.” However, safety findings from trials — notably the FHN Nocturnal trial reporting higher mortality and more adverse events in the nocturnal arm — underscore that some intensive home HD regimens may pose increased risks and therefore may not be appropriate for coverage absent fulfillment of the policy criteria.

NKF/KDOQI guidance notes that data on long or frequent home hemodialysis are inconclusive and that there is potential for increased harm and mortality with some regimens. The Work Group did not make firm recommendations for home long frequent HD, highlighting the need for cautious application and individualized risk assessment when considering extended or more frequent home dialysis schedules.

Procedure and Billing Codes

Referenced Procedure CodesCPT | HCPCS

90963	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.
90964	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.
90965	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents.
90966	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 20 years of age and older.
90967	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age.
90968	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2-11 years of age.
90969	End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12-19 years of age.
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.

1–10 of 12

1/2

Applicable CPT Codes noted in revisionCPT

90963
90964
90965
90967
90968
90969

inv-12: spKt/V target — Target adequacy metrics for thrice-weekly hemodialysis sessions

Target spKt/V per thrice-weekly HD session1.4 single-pool Kt/V per hemodialysis session (minimum delivered 1.2)

Source guideline2015 NKF/KDOQI hemodialysis adequacy guideline recommends 1.4 spKt/V per thrice-weekly session

Adjustment for residual kidney functionDose may be reduced in patients with significant residual native kidney function (Kru) with periodic measurement to avoid inadequate dialysis

Indication to increase doseConsider additional sessions or longer treatment times for large interdialytic weight gains, high ultrafiltration rates, uncontrolled BP, or poor metabolic control

Provider Responsibilities, Documentation, and Authorization

Prior Authorization

Procedure Codes and Prior Authorization

Procedure code reference / potential prior authorization: The Applicable Codes list is provided for reference and may not be all inclusive. Procedure codes listed in the policy should be verified against the member's specific benefit plan, federal/state contractual requirements, and applicable laws. Codes may be subject to benefit determination and prior authorization depending on the plan; providers should confirm prior authorization needs with UnitedHealthcare before scheduling services.

Verify procedure and diagnosis codes against the member's plan.
Confirm whether prior authorization is required for home hemodialysis services under the member's benefit contract.

Note

No Additional Provider Actions Specified

None specified in this segment: The policy excerpts provided do not list explicit additional provider actions beyond standard verification of benefit, documentation, and training requirements. Clinicians should follow plan rules and any tools UnitedHealthcare uses (e.g., InterQual) for coverage determinations.

Background and Rationale

Hemodialysis provides renal replacement by combining ultrafiltration and diffusionnon‑skilled HHD) or by trained staff (skilled HHD); coverage depends on meeting the specific stability, training, safety, and vascular access criteria outlined in the policy.

Definitions and Key Terms

inv-26: Vascular access — Describes AVF, AVG, and indwelling catheter options relevant to HHD

Arteriovenous fistula (AVF)Surgically created connection between an artery and vein; gold standard access with fewer complications; requires needle sticks for cannulation

Arteriovenous graft (AVG)Synthetic conduit between artery and vein used when native vessels are unsuitable; higher complication rates than AVF

Indwelling dialysis catheterTunneled central venous catheter inserted into a large central vein; avoids needle sticks but carries higher infection risk

Relevance to HHDPatients performing HHD are encouraged to learn AVF/AVG cannulation; catheter use increases infection risk and is less preferred

inv-27: Home hemodialysis (HHD) — Definition distinguishing non-skilled (patient/caregiver) vs skilled (staff-assisted) home hemodialysis

Policy Revision History

05/01/2025Policy revisionLatest

Updated coverage criteria to allow home hemodialysis without skilled care as an alternative to facility-based hemodialysis and revised vascular access wording to require that the individual has well‑functioning vascular access; updated Description of Services, Clinical Evidence, FDA, and References sections.

05/01/2025Coding change

Removed notation that CPT codes 90963, 90964, 90965, 90967, 90968, and 90969 are not on the State of New Jersey Medicaid Fee Schedule (state-specific coverage verification required).

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for New Jersey Only)

Policy CodePolicy CS057NJ.L

Change TypeCoverage criteria revisedcoding notation removed

Effective DateMay 1, 2025

Next Review DateN/A

SourceLink

On This Page

Findings tempered by low power and trial limitations.

Systematic reviews/meta-analyses: Systematic reviews conclude low strength of evidence that more frequent/longer HD may improve BP, LV mass, QoL/symptom measures and possibly mortality in selected populations, but with higher vascular access complication rates and overall low/very low quality evidence.

Examples: Shafi et al. 2020; Mathew et al. 2018; Miller et al. 2018.

Device-specific evidence: Small non-randomized studies of devices (e.g., Tablo system) report achievement of prescribed dialysis adequacy and ultrafiltration targets with no device-related AEs in limited samples; generalizability limited by small, younger participant populations.

Special populations: In pregnancy, greater dialysis hours per week are associated with preterm delivery and small-for-gestational-age infants; dialysis schedule is a determinant of outcomes in pregnancy on dialysis.

Source: Piccoli et al. 2016 systematic review.

Documentation Required

Safety Endpoints and Study Outcomes

Safety endpoints and study outcomes that may inform monitoring and documentation: Clinical studies reported outcomes and safety endpoints relevant to HHD monitoring, including weekly standard Kt/Vurea (e.g., target ≥ 2.1), delivery of ultrafiltration within 10% of prescribed UF, adverse events counts, treatment time recovered (TTR), patient-reported general health and sleep quality, hospitalization and mortality outcomes from observational cohorts and systematic reviews. Providers may use these endpoints to guide documentation of treatment efficacy and safety.

Weekly standard Kt/Vurea (target example: ≥ 2.1 used in studies)
Ultrafiltration delivery within 10% of prescribed UF
Adverse events observed during HHD vs in-center HD
Treatment time recovered (TTR) and patient-reported outcomes (QOL, sleep)
Hospitalization and mortality metrics from observational studies and systematic reviews

Denial Risk

Plan-Specific Requirements and Potential Denial Triggers

Plan-specific requirements may trigger denial: Coverage and payment decisions must follow federal, state, or contractual benefit plan requirements. If plan-specific eligibility, prior authorization, documentation, or provider-network requirements are not met (for example, instability on dialysis, need for skilled interventions during treatments, inadequate training or caregiver support, or missing required documentation), services may be denied.

Coverage is governed by the member's federal, state, or contractual benefit plan — these terms supersede this policy when conflicts exist.
Services may be denied if the individual is not stable on dialysis, requires skilled care during treatments, lacks ability or adequate training/caregiver support, or if required documentation is incomplete.

Documentation Required

Documentation and Review Instructions

Documentation and review instructions: Document clinical stability on dialysis, presence of well-functioning vascular access, absence of contraindications, completion of comprehensive training by the patient and/or caregiver, and any clinical indications for skilled home hemodialysis when applicable. Review the member's federal/state/contractual benefit terms and check for any required prior authorization or use of utilization review tools.

Record evidence the individual is stable on dialysis and does not require skilled interventions during home treatments.
Document training completion for patient and/or caregiver and ongoing competency as applicable.
Confirm and document well-functioning vascular access and absence of complications that would make HHD unsafe.
Check and document any required prior authorization or use of third-party tools (e.g., InterQual) per UnitedHealthcare guidance.

Step Therapy

Step therapy: No specific step therapy requirements are described in the provided policy excerpts. There is no explicit step-therapy pathway required prior to home hemodialysis described here; however, clinicians should verify plan rules for any step-therapy or care-model requirements.

No step therapy stated in this policy segment.
Verify whether the member's plan imposes any step therapy or sequencing requirements before authorizing HHD.

Home hemodialysis (HHD) — non-skilled

Dialysis performed at home by the patient or a non‑professional caregiver after comprehensive training; requires ability to perform and maintain HHD and suitable home environment

Home hemodialysis (HHD) — skilled (staff-assisted)Dialysis performed at home by trained staff when the patient/caregiver cannot perform HHD or has medical contraindication to leaving home; protocols generally match in-center care

Training requirementComprehensive training of patient or caregiver is required before non‑skilled HHD is covered

inv-28: Usual care / More frequent / Longer HD — Definitions for treatment frequency and duration terms used in the policy and evidence

Usual careIn-center hemodialysis three times per week with less than 4 hours per treatment

More frequent hemodialysisFour or more treatments per week

Longer hemodialysisTreatments of 4 or more hours per session

Policy contextDefinitions used in evidence syntheses and to guide when additional sessions/longer times are considered for clinical indications

inv-29: Single pool Kt/V (spKt/V) target for thrice-weekly hemodialysis — Short definition/target reference

spKt/V (single-pool Kt/V)Measure of dialysis dose; NKF/KDOQI recommends target spKt/V of 1.4 per hemodialysis session for thrice-weekly treatment (minimum delivered 1.2)

Clinical purposeUsed to assess adequacy of solute removal per dialysis session and guide prescription adjustments

Guideline reference2015 NKF/KDOQI hemodialysis adequacy guideline; AHA notes home dialysis can improve cardiovascular outcomes but more studies needed