90945 Insurance Policy Changes

CPT 90945, in plain terms, covers A dialysis session that is not hemodialysis, such as peritoneal dialysis or hemofiltration, where the physician checks on the patient once during the treatment. CPT 90945 is referenced in 6 tracked payer policy changes from Michigan Medicaid - MDHHS, Nevada Medicaid, and 2 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 90945 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Official descriptor: CPT 90945 on AAPC

Michigan Medicaid - MDHHS · Effective Oct 1, 2026High impact
MMP 26-36: Updates to the MDHHS Medicaid Provider Manual
Effective October 1, 2026, MDHHS requires outpatient hospital and ambulatory surgical center providers to report modifier SL with the appropriate procedure code for certain pediatric immunization services rendered to beneficiaries under 19 years of age. Procedure codes with an SL modifier requirement will be denied if modifier SL is not reported for beneficiaries under 19 years of age, and will be denied if modifier SL is reported for beneficiaries over 19 years of age. Non-routine therapies do not require prior authorization for Medicaid beneficiaries residing in a skilled nursing facility within 60 days of their admission to the facility.
Nevada Medicaid · Effective Jan 1, 2026Medium impact
Attention Provider Types 45 (End Stage Renal Disease (ESRD) Facility) and 81 (Hospital Based ESRD Provider): Rates for Dialysis Codes 90945 and 90999 Adjusted for 2026
Nevada Medicaid has adjusted reimbursement rates for dialysis CPT codes 90945 and 90999 effective January 1, 2026. This affects ESRD facilities and hospital-based ESRD providers billing Nevada Medicaid for peritoneal dialysis and unlisted dialysis procedures.
Michigan Medicaid - MDHHS · Effective Oct 1, 2025Medium impact
MMP 25-40: Updates to the MDHHS Medicaid Provider Manual; Behavioral and Physical Health and Aging Services Administration (BPHASA) Reorganized and Renamed Health Services
The October 2025 update to the MDHHS Medicaid Provider Manual renames the Behavioral and Physical Health and Aging Services Administration (BPHASA) to Health Services throughout the manual and incorporates bulletins MMP 25-10 through MMP 25-25. Its dialysis changes state that hemodialysis codes such as 90935 and 90937 describe the procedure with all related E/M services on the day of the procedure, and that dialysis codes such as 90945 and 90947 cover other dialysis procedures. Other billing changes cover timed therapy minutes, recuperative care prior authorization, emergency ambulance claim coding, dental secondary claims for dually eligible beneficiaries, and electronic visit verification for Home Help services.
Aetna · Identified Oct 1, 2026Medium impact
Dialysis (CPB 0541, reviewed 2026-08-26)
Aetna's dialysis policy (CPB 0541), last reviewed 08/26/2026, considers hemodialysis or intermittent peritoneal dialysis up to 3 times per week medically necessary for renal failure. More frequent dialysis is considered medically necessary when hyperkalemia, hypophosphatemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema or severe catabolic state is refractory to dialysis 3 times per week. Home hemodialysis equipment, supplies and skilled nursing visits are considered medically necessary when prescribed by a physician for members with end stage renal disease, and the equipment is usually rented during the first 30 months of hemodialysis.
Aetna · Identified Aug 14, 2026Medium impact
Dialysis (CPB 0541, reviewed 2025-11-26)
Aetna considers hemodialysis or intermittent peritoneal dialysis up to 3 times per week medically necessary for renal failure, and more than 3 times per week when hyperkalemia, hypophosphatemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema, or severe catabolic state is refractory to dialysis 3 times per week. Home hemodialysis is medically necessary when prescribed by a physician for members with end stage renal disease, and percutaneous arteriovenous fistula creation is considered medically necessary as an alternative to surgical creation. Angioplasty using FDA-approved plain or drug-coated balloons is considered medically necessary for dysfunctional arterio-venous dialysis fistulae, while wearable hemodialysis machines and the Crit-Line In-Line Monitor are considered experimental, investigational, or unproven.
Blue Cross & Blue Shield of Mississippi · Identified Jun 20, 2026Medium impact
Continuous Arteriovenous Hemofiltration
Continuous renal replacement therapy may be considered medically necessary as supportive treatment for acute renal failure. CPT 90945 and 90947 cover dialysis procedures other than hemodialysis, including hemofiltration and other continuous renal replacement therapies. The policy was reviewed on 01/14/2026 with its policy statement unchanged, and ICD-9 diagnosis codes were removed from the code reference.

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REFERENCE DATA

Payers with rules2

Payers requiring prior auth2

CalViva Health · Effective December 31, 2025
Prior authorization required
CalViva Health CMS-0057-F prior authorization requirements
Community Health Plan of Imperial Valley · Effective December 31, 2025
Prior authorization required
Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does CalViva Health require prior authorization for 90945?

CalViva Health lists 90945 on CalViva Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Community Health Plan of Imperial Valley require prior authorization for 90945?

Community Health Plan of Imperial Valley lists 90945 on Community Health Plan of Imperial Valley CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect CPT 90945?

There are 6 tracked policy changes affecting CPT 90945, including updates from Michigan Medicaid - MDHHS, Nevada Medicaid, Aetna. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 90945?

Payers that have issued tracked updates for CPT 90945 include: Michigan Medicaid - MDHHS, Nevada Medicaid, Aetna, Blue Cross & Blue Shield of Mississippi.

How do I get notified when CPT 90945 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 90945. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 90945?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for 90945 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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MMP 26-36: Updates to the MDHHS Medicaid Provider Manual

Attention Provider Types 45 (End Stage Renal Disease (ESRD) Facility) and 81 (Hospital Based ESRD Provider): Rates for Dialysis Codes 90945 and 90999 Adjusted for 2026

MMP 25-40: Updates to the MDHHS Medicaid Provider Manual; Behavioral and Physical Health and Aging Services Administration (BPHASA) Reorganized and Renamed Health Services

Dialysis (CPB 0541, reviewed 2026-08-26)

Dialysis (CPB 0541, reviewed 2025-11-26)

Continuous Arteriovenous Hemofiltration

Prior authorization required