0692T — Therapeutic ultrafiltration
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Clinical documentation demonstrating fluid overload and failure of medical management, including trials and responses to diuretics.
- Patient weight documented as ≥20 kilograms.
- Physician prescription/order specifying temporary (≤8 hours) or extended (>8 hours) therapy and setting (inpatient vs outpatient).
- Documentation that treating healthcare provider and prescribing physician have received training in extracorporeal therapies.
Key Coverage Criteria
- Use of ultrafiltration (aquapheresis) to remove intravascular fluid in hospitalized patients with marked volume overload from decompensated heart failure, particularly when refractory to conventional medical therapy (technique under investigation).
- Ultrafiltration for removal of excess volume and sodium in patients with decompensated heart failure whose fluid overload is unresponsive to medical management.
- Temporary (≤8 hours) ultrafiltration for patients with fluid overload who have failed diuretic therapy.
- Extended (>8 hours) ultrafiltration for hospitalized patients with fluid overload who have failed diuretic therapy.
- Continuous ultrafiltration therapy (temporary, up to 8 hours) with the Aquadex FlexFlow System 2.0 for adult and pediatric patients weighing ≥20 kg with fluid overload unresponsive to medical management including diuretics.
- Extended continuous ultrafiltration therapy (longer than 8 hours) with the Aquadex FlexFlow System 2.0 for adult and pediatric patients weighing ≥20 kg with fluid overload unresponsive to medical management including diuretics, when the patient is hospitalized.
5 Active Policies
BCBSIL-MED202.062 — Ultrafiltration in Decompensated Heart Failure
BCBSMT-MED202.062 — Ultrafiltration in Decompensated Heart Failure
BCBSNM-MED202.062 — Ultrafiltration in Decompensated Heart Failure
BCBSOK-MED202.062 — Ultrafiltration in Decompensated Heart Failure
MED202.062 — Ultrafiltration in Decompensated Heart Failure
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