Does 90967 require prior authorization?

No, 90967 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 90967?

Medicare facility rate: $18.37. Non-facility rate: $18.37. Work RVU: 0.35.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.35

Facility

$18.37

Non-Facility

$18.37

Diagnosis documentation: medical record documenting diagnosis of end-stage renal disease (ESRD) and indication for renal replacement therapy.
Clinical stability: documentation that the individual is 'stable on dialysis' (clinical notes, dialysis session records) and notation that no skilled care interventions are required during routine treatments for coverage without skilled care.
Training records: evidence of comprehensive training completion for the patient and/or non-professional caregiver (e.g., completed course CPT 90989 or per-session 90993 where applicable), including competency assessment.
Caregiver capability: documentation that a non-professional caregiver is available, trained, and able to assist (if applicable) or documentation that patient/caregiver is not capable (for skilled care pathway).

Home hemodialysis (HHD) as an alternative to facility-based hemodialysis for individuals with end-stage renal disease (ESRD) who meet ALL of the following (HHD without skilled care): individual is stable on dialysis with no evidence of skilled care interventions being necessary during treatments; and the individual undergoing hemodialysis or a non-professional caregiver has the ability to perform and maintain home hemodialysis and has received comprehensive training regarding proper protocol; an [...]
Home hemodialysis WITH skilled care as an alternative to facility-based hemodialysis for individuals with ESRD who meet ALL of the following: individual is stable on dialysis and not at increased risk as a result of having the procedure performed outside a dialysis center venue; and the individual undergoing hemodialysis or non-professional caregiver is NOT capable of performing home hemodialysis; and the individual has medical contraindications to leaving home for hemodialysis; and individual h [...]
HHD for pediatric patients as applicable under ESRD-related services codes (CPT 90963–90969) when the patient meets the general coverage rationale and age-specific CPT definitions apply (codes listed in policy for reference).
Services and per-diem administrative/care coordination/supplies for home hemodialysis (HCPCS S9335) when provided as described and when member meets coverage criteria and benefit plan provisions (codes listed in policy for reference).

UHC-POL-home-hemodialysis — Home Hemodialysis

UMR-POL-UMR-home-hemodialysis — Home Hemodialysis

SUREST-POL-SUREST-home-hemodialysis — Home Hemodialysis

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