90937
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.06
Facility
$88.51
Non-Facility
$88.51
Documentation Required
- No specific documentation requirements, required medical records, or test-result documentation are stated in this policy.
- Physician prescription is required for home hemodialysis and for use of portable/home hemodialysis systems (NxStage, Tablo).
- When using devices or modalities with limited evidence (portable machines, wearable devices, bioengineered vessels, DCB angioplasty, BCM, ViE-m, HIF-PHIs), documentation should include indication, supporting clinical rationale, and acknowledgment of current evidence limitations (implicit from text recommending further study and noting limitations).
- Records supporting the need for specific equipment or supplies (e.g., demonstration of home water quality to justify a water softening system when RO is used).
Key Coverage Criteria
- No covered indications identified. Hemodialysis for the treatment of schizophrenia is considered experimental and investigational because the effectiveness of this approach has not been demonstrated and established.
- Hemodialysis or intermittent peritoneal dialysis for renal failure up to 3 times per week.
- Hemodialysis and intermittent peritoneal dialysis performed more than 3 times per week for renal failure when one or more of the following conditions are present and refractory to dialysis 3 times per week: hyperkalemia (E87.5), hypophosphatemia (E83.39), pregnancy (O00.0-O9A.53; Z33.1; Z33.3; Z3A.00-Z3A.49), fluid overload (E87.70-E87.79), acute pericarditis (I30.0-I30.9), congestive heart failure (I50.1-I50.9), pulmonary edema (J81.0-J81.1), or severe catabolic state/age-related physical debil [...]
- Home hemodialysis when prescribed by a physician for members with end-stage renal disease (N18.6).
- Up to 1 month's supplies in reserve in case of emergency are considered medically necessary; this is a one-time allowance.
- CPT codes covered if selection criteria is met: 90935, 90937, 90999, 99512 (hemodialysis-related codes).
2 Active Policies
AETNA-CPB-0541 — Dialysis
AETNA-CPB-0291 — Hemodialysis for Schizophrenia
Related Codes
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