E1630, Reciprocating peritoneal dialysis system
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- 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).
- Documentation of initiation circumstances if emergency reserve supplies are provided (one-time allowance up to 1 month).
Key Coverage Criteria
- 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).
- Tablo Hemodialysis System ... is FDA cleared for use in patients with acute and/or chronic renal failure, with or without ultrafiltration, in an acute or chronic care facility. ... The Tablo Hemodialysis System is also indicated for use in the home (FDA, 2020).
1 Active Policy
AETNA-CPB-0541, Dialysis
Related Codes
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