ModifiedUnitedHealthcarePolicy CS057OH.C

Home Hemodialysis (for Ohio Only)

Policy governs coverage and medical necessity criteria for home hemodialysis (HHD) in Ohio for UnitedHealthcare Community Plan members, including both unassisted HHD and staff-assisted HHD.

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for Ohio Only)

Policy CodePolicy CS057OH.C

Change TypeRevised coverage criteria wordingadministrative updates

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization using UnitedHealthcare processes and document stability on dialysis, training completion, and presence of well-functioning vascular access.

SourceLink

POLICY UPDATE CHANGES

Updated coverage criteria for home hemodialysis without skilled care as an alternative to facility-based hemodialysis, replacing criterion requiring 'presence of well-functioning vascular access' with 'individual has well-functioning vascular access'.

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

Related Policies: updated reference link to current policy title for Home Health, Skilled, and Custodial Care Services (for Ohio Only).

Ohio-onlyGeographic applicability

2HHD care models

3x/weekTypical staff-assisted protocol

Very low–low

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

1.8%Current U.S. HHD proportion

Coverage and Medical Necessity Criteria

Unassisted (without skilled care) HHD

Covered when ALL of the following are met

Unassisted HHD medical necessity: Individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments; individual or non-professional caregiver has ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; absence of complications and significant concomitant disease that would make HHD unsafe or unsuitable; individual has well-functioning vascular access.

From Coverage Rationale

Staff-assisted (with skilled care) HHD

Covered when ALL of the following are met

Staff-assisted HHD medical necessity: Individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center; individual or 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 with frequency/duration determined by attending nephrologist.

From Coverage Rationale; typical protocol 3x/week, 3–4 hours

Coverage considerations for frequent or home hemodialysis

Consider coverage when ALL of the following patient-level clinical criteria are documented:

Candidate selection: Patient has end-stage renal disease and clinical problems potentially responsive to more frequent or home hemodialysis (examples: poor volume control, uncontrolled hypertension, left ventricular hypertrophy, or need for improved phosphate control).clinical judgment

Supported by trials showing improved BP, LV mass, and volume control in selected patients

Risk assessment: Patient has an acceptable vascular access risk profile or there is a documented plan to mitigate increased access interventions associated with more frequent or extended-length hemodialysis.clinical judgment

Multiple studies reported increased vascular access procedures with frequent/extended HD

Program support: Documented multidisciplinary home dialysis support is available (training, nursing, monitoring) and device-specific support is present if a particular home system is used.

Coverage Rationale (summary)

Covered when ALL of the following are met (policy-level summary from revision):

Home hemodialysis without skilled care coverage: Home hemodialysis without skilled care is an alternative to facility-based hemodialysis for treating individuals with end-stage renal disease when the policy criteria are met.

Revised wording updated to person-first phrasing regarding well-functioning vascular access; see Policy History/Revision Information.

Individuals with complications or significant concomitant disease that would make home hemodialysis (HHD) unsafe or unsuitable are excluded from coverage as HHD candidates. This follows the policy requirement that the patient have an absence of complications and significant comorbid conditions that would cause HHD to be unsafe or unsuitable, and be otherwise stable on dialysis and able to perform HHD (or have a capable non‑professional caregiver) as applicable.

More frequent (greater than 3 times per week) or extended‑length hemodialysis should not be used routinely in patients at high risk for vascular access complications without a clear, documented clinical indication. Systematic reviews and trials reported an increased number of vascular access procedures with more frequent or longer HD, and this safety signal should be considered when evaluating candidates for intensified or extended treatments.

The NKF/KDOQI Work Group stated that, because of inconclusive evidence and potential for increased harm or mortality, no firm recommendations could be made regarding home long frequent hemodialysis. The Work Group additionally noted the absence of randomized trials for home short‑frequent HD and limited evidence to guide home long‑frequent protocols.

Home hemodialysis is considered not medically necessary when the individual requires skilled care interventions during dialysis treatments, or when safe performance of HHD is not possible due to inadequate training, inability of the patient or caregiver to perform necessary tasks, or poor vascular access. Requests meeting these conditions are subject to denial under the policy.

Routine use of more‑than‑thrice‑weekly HD or extended‑length HD in unselected patients without documented clinical indications is not supported by consistent evidence of improved clinical outcomes. Available systematic reviews found no clear advantage of routine intensified or extended regimens and reported higher rates of vascular access procedures, so such approaches require specific justification in the individual patient.

Evidence summaries indicate that, during relatively short follow‑up, more‑than‑thrice‑weekly hemodialysis and extended‑length hemodialysis did not improve clinical outcomes compared to conventional HD and were associated with an increased number of vascular access procedures. The overall quality of evidence for these comparisons was very low to low, and many studies were underpowered for mortality endpoints.

Procedure Codes, Devices, and Technical Targets

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

FDA-cleared devices for home hemodialysis (informational list)mixed

2008K@home	Hemodialysis Machine (Fresenius Medical Care)
NxStage System One	NxStage Medical, Inc. home hemodialysis system
NxStage Versi HD	NxStage Versi HD with GuideMe software (NxStage Medical, Inc.)
Quanta Dialysis System	Quanta Dialysis Technologies, Ltd.
Tablo	Tablo Hemodialysis System (Outset Medical, Inc.)

Typical staff-assisted protocol frequency/duration

Typical staff-assisted frequency3 times per week

Typical staff-assisted duration3-4 hours per treatment

Protocol determinationExact dialysis therapy is individualized by the attending nephrologist

Kt/Vurea weekly standard

Weekly standard Kt/Vurea threshold≥ 2.1

Study achieving weekly standardTablo study (Plumb et al.) reported average weekly standard Kt/Vurea of 2.8 in both in-center and HHD periods

Prior Authorization, Documentation, and Denial Risk

Prior Authorization

Procedure codes and prior authorization note

Prior authorization requirements apply. The list of procedure and diagnosis codes in this policy is provided for reference and does not guarantee coverage; listing of a code does not imply the service described is a covered benefit. Providers must obtain prior authorization when required by the member’s benefit plan and UnitedHealthcare processes.

Procedure/diagnosis codes listed in the policy are for convenience only; verification of benefit coverage is required.
Prior authorization is required when indicated by the member’s plan — check payer portals or prior auth tools.

Prior Authorization

Prior authorization: clinical indication and risk/benefit

Prior authorization should require documentation of the clinical indication and an assessment of the balance of benefits and risks. Evidence shows potential benefits (improved blood pressure control, reduced LV mass, quality-of-life gains) for selected patients with home hemodialysis, but also an increased risk of vascular access complications with more frequent or longer treatments. Prior auth reviewers should ensure the requested HHD modality is appropriate for the patient given trial populations and device differences.

Background and Evidence Summary

Hemodialysis (HD) is a renal replacement therapy that removes waste and excess fluid using an extracorporeal circuit combining ultrafiltration and diffusion. Conventional HD is typically performed in a dialysis center three times per week with treatments lasting about 3–4 hours. Home hemodialysis (HHD) enables delivery of HD in the home using machines designed with safety features; HHD may be provided without skilled assistance when the patient or non‑professional caregiver is trained and the individual is stable on dialysis, or with staff assistance when the patient cannot safely travel or perform HHD independently.

Definitions and Clinical Targets

Vascular access

Arteriovenous fistula (AVF)Preferred vascular access due to far fewer complications

Arteriovenous graft (AVG)Synthetic conduit between artery and vein; alternative when AVF not possible

Indwelling dialysis catheterNo skin puncture but increases infection risk; used when other accesses unavailable

Staff-assisted HHD (definition)

DefinitionHome hemodialysis performed at the individual's home with skilled staff assisting when the patient or caregiver cannot perform HHD

IndicationsUsed when individual is not capable of performing HHD or has medical contraindications to leaving home

Policy Revision History

2025-09-01related_policy_update

Updated reference link to reflect the current policy title for Home Health, Skilled, and Custodial Care Services (for Ohio Only).

2025-06-01coverage_rationale_revisionLatest

Revised coverage criteria wording: home hemodialysis without skilled care affirmed as an alternative to facility-based hemodialysis and the criterion wording changed from 'presence of well-functioning vascular access' to 'individual has well-functioning vascular access'; supporting sections (Description of Services, Clinical Evidence, FDA, References) were updated and prior version CS057OH.B was archived.

Policy Summary

PayerUnitedHealthcare

PolicyHome Hemodialysis (for Ohio Only)

Policy CodePolicy CS057OH.C

Change TypeRevised coverage criteria wordingadministrative updates

Effective DateJun 1, 2025

Next Review Date

Key ActionSubmit prior authorization using UnitedHealthcare processes and document stability on dialysis, training completion, and presence of well-functioning vascular access.

SourceLink

On This Page

program availability

Systematic reviews associate home dialysis benefits when implemented with program support

Modality-specific evidence: There is evidence of benefit in patient populations similar to the candidate (e.g., studies showing reduced LV mass, improved blood pressure control, or improved quality of life) or a documented contraindication to feasible in-center modifications.study relevance

Benefits were most evident in selected trial populations and may not generalize to older or more comorbid patients

Used as primary efficacy endpoint in prospective Tablo HHD study

spKt/V target

spKt/V target per sessionTarget single pool Kt/V (spKt/V) of 1.4 per hemodialysis session

Minimum delivered spKt/VMinimum delivered spKt/V of 1.2

ApplicabilityTarget applies to patients treated thrice weekly; consider residual kidney function when dosing

Document clinical indication for HHD and why it is expected to provide net benefit for this patient.

Acknowledge evidence limitations (low strength of evidence for some outcomes) and potential increased risk of vascular access complications.

Prior Authorization

Prior authorization and criteria

Providers must follow UnitedHealthcare prior authorization processes and supply documentation necessary to demonstrate that applicable medical necessity criteria (including InterQual when available) are met for home hemodialysis (HHD). If InterQual criteria are used, documentation should map to those criteria.

Follow payer-specific prior authorization submission workflows (portal, fax, or phone) and include clinical records.
UnitedHealthcare may apply InterQual® criteria or other approved guidelines to determine medical necessity for HHD.

Denial Risk

Clinical triggers for denial

Deny when clinical triggers indicate HHD is unsafe or not appropriate. Examples include patients who are not stable on dialysis, require skilled care during treatments, or lack the cognitive/physical ability and caregiver support to perform HHD safely.

Denial triggers include: not stable on dialysis, ongoing need for skilled interventions during dialysis, lack of patient or caregiver ability or completion of training, unsuitable home environment, or medical contraindications to home treatment.

Denial Risk

Vascular access complications risk

There is a documented safety signal for increased vascular access complications with more frequent or longer hemodialysis regimens. Prior authorization and clinical decision-making should weigh these risks against potential benefits and ensure vascular access is functioning well before approving HHD.

Increased frequency/longer sessions associated with higher rates of access complications in trials.
Confirm presence of a well-functioning vascular access and plan for monitoring/management of access complications.

Note

Verify governing benefit terms

Coverage decisions must reference and, when applicable, defer to federal requirements, state rules (including the Ohio Administrative Code), and the member’s contractual benefit terms. In the event of conflict, those governing terms take precedence over this policy.

Verify federal, state (OAC), and contractual benefit terms before approving or denying services.
When federal/state/contractual requirements differ from this policy, follow those requirements.

Documentation Required

Patient selection documentation

Document patient selection details to support medical necessity. Include evidence the patient is stable on dialysis, has completed and passed HHD training, possesses the physical and cognitive ability (or has a committed caregiver) to perform HHD, and has a suitable, safe home environment.

Document stability on dialysis and absence of complications that would make HHD unsafe.
Include training completion records and assessment of patient/caregiver competency.
Describe home environment adequacy and presence of well-functioning vascular access.

Step Therapy

Stepwise consideration for home dialysis

Consider HHD using a stepwise approach: evaluate patient suitability, ensure training and supports, start with a conservative regimen when appropriate, and escalate frequency or session length only when clinically justified. Evidence suggests home-based dialysis may reduce mortality and hospitalizations for selected patients, but selection and monitoring are critical.

Step 1: Assess suitability — stability, access function, caregiver/support, home environment.
Step 2: Complete training and competency assessment for patient/caregiver.
Step 3: Begin HHD with a tailored regimen and monitor outcomes, access status, and adverse events.
Step 4: Modify frequency or duration only with documented clinical justification and monitoring plan.

Staff-assisted protocols generally match in-center protocols (frequency/duration determined by nephrologist)

Usual care / conventional HD

DefinitionIn-center hemodialysis performed three times per week with less than 4 hours per treatment

ContextDefined as 'usual care' comparator in systematic reviews of more frequent or longer HD

CommonalityConventional in-center HD is the standard comparator for trials of intensified regimens

More frequent HD

DefinitionMore frequent hemodialysis is defined as four or more treatments per week

Evidence noteMultiple studies reported increased vascular access procedures with more frequent HD

ConsiderationConsider patient selection and access risk before initiating frequent regimens

Longer HD

DefinitionLonger hemodialysis is defined as four or more hours per treatment

NKF/KDOQI noteConsider longer treatments for patients with large weight gains, high ultrafiltration rates, or poor metabolic control

Evidence cautionHome long frequent HD recommendations were limited due to inconclusive data and potential increased risk

Conventional hemodialysis typical schedule

Typical conventional schedule3 to 5 hours per treatment, three days per week

Common practiceConventional HD remains the most common treatment worldwide

PurposeSchedule aims to provide adequate ultrafiltration and solute clearance while fitting patient routines

spKt/V target

Target spKt/V per sessionTarget single pool Kt/V (spKt/V) of 1.4 per hemodialysis session

Minimum delivered spKt/VMinimum delivered spKt/V of 1.2

ApplicabilityRecommendation specified for patients treated thrice weekly; adjust for residual kidney function as indicated