N18.6 Insurance Policy Changes

ICD-10 N18.6 is officially defined as "End stage renal disease." code N18.6 is referenced in 24 tracked payer policy changes from Horizon BCBS NJ, Independence Blue Cross, and 6 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for code N18.6 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Horizon BCBS NJ · Effective Jan 1, 2026High impact
Statin Use in Persons with Diabetes (SUPD)
This is a new Medicare Part D Star Ratings measure (SUPD) effective for 2026 that evaluates whether patients ages 40-75 with diabetes on antidiabetic medications are also receiving statin therapy. Billing teams must ensure proper documentation and ICD-10 coding of exclusionary diagnoses to accurately track eligible patients and avoid measure performance penalties. Claims must include appropriate exclusion codes when patients have contraindications to statin therapy.
Independence Blue Cross · Effective Jun 29, 2026Medium impact
MA08.011i, Erythropoiesis Stimulating Agents (ESAs)
Independence Blue Cross updated MA08.011i to align with FDA labeling and NCCN guidelines for Erythropoiesis Stimulating Agents (ESAs). The policy revises medical necessity criteria for myelodysplastic syndrome, cancer-related anemia, HIV/AIDS, and pediatric chronic kidney disease, and adds 18 new ICD-10 diagnosis codes effective June 29, 2026.
Independence Blue Cross · Effective Jun 15, 2026Medium impact
08.00.75r, Erythropoiesis-Stimulating Agents (ESAs)
Independence Blue Cross updated policy 08.00.75r on Erythropoiesis-Stimulating Agents (ESAs) effective June 15, 2026, revising coverage criteria for myelodysplastic syndrome, cancer-related anemia, HIV/AIDS, and pediatric chronic kidney disease based on updated FDA labeling and NCCN guidelines. Multiple ICD-10 diagnosis codes were added to the policy to align with current diagnostic classifications. Billing teams must update systems to recognize these new diagnosis codes when processing ESA claims.
Capital Blue Cross · Effective Apr 1, 2026Medium impact
AB2026-04-002 Medicare only
Capital Blue Cross updated Medicare Part D Star measures for 2026, adding new exclusions for Statin Use in Persons with Diabetes (SUPD) that recognize PCSK9 inhibitors and bempedoic acid as alternatives for patients who cannot tolerate statins. Providers must submit specific ICD-10-CM codes annually during in-person or audio/video visits to qualify patients for exclusions from the SUPD measure.
Aetna · Identified Nov 4, 2026Medium impact
Selected Kidney Function Tests (CPB 0775, reviewed 2026-10-28)
Aetna's Clinical Policy Bulletin 0775 (reviewed 2026-10-28) designates multiple advanced kidney function tests as experimental, investigational, or unproven, including KidneyIntelX, IntelxDKD, NaviDKD, PromarkerD, RenalVysion, RenaDx, RenaXome, GFR NMR, APOL1 genotyping, and transdermal pyrazine-based GFR measurement. Claims for these tests will be denied when billed with the specified CPT codes and ICD-10 indications listed in the policy.
Aetna · Identified Oct 23, 2026Medium impact
Analysis of Volatile Organic Compounds (CPB 0717, reviewed 2026-10-20)
Aetna considers analysis of volatile organic compounds experimental, investigational or unproven for many indications, including detection of cancer, diagnosis of infection, diagnosis of lung disease such as asthma, diagnosis of tuberculosis and pneumonia, screening for COVID-19, and diagnosis of Parkinson's disease, because the clinical effectiveness of this technique has not been established. The policy states that there is no specific CPT code for analysis of volatile organic compounds. Its ICD-10 table lists diagnosis codes for which the analysis is not covered, and that list is not all-inclusive.
Aetna · Identified Oct 5, 2026Medium impact
Thrombectomy Systems (CPB 0568, reviewed 2026-09-18)
Aetna considers the AngioJet Rheolytic Thrombectomy System medically necessary for removing fresh blood clots from arterio-venous fistulas used for hemodialysis, from coronary arteries or coronary bypass grafts that are at least 2.0 mm in diameter before angioplasty or stent placement, and from infra-inguinal peripheral arteries at least 2.0 mm in diameter. It also considers the system medically necessary for individuals with lower extremity deep vein thrombosis who have failed pharmacologic thrombolysis or in whom pharmacologic thrombolysis is contraindicated. Aetna considers the AngioJet system experimental, investigational or unproven for acute aortic occlusion, acute renal artery thrombosis, cerebral venous sinus thrombosis, inferior vena cava filter-related thrombosis, May-Thurner syndrome-related deep venous thrombosis, pulmonary embolism, and thrombosis of the native aortic valve and of the left ventricular assist device in individuals with heart failure. Aetna also considers the ClotHunter system for lower extremity deep vein thrombosis, and mechanical thrombectomy and/or thrombo-aspiration for acute ilio-femoral deep vein thrombosis, experimental, investigational or unproven.
Aetna · Identified Oct 4, 2026Medium impact
Heart Transplantation (CPB 0586, reviewed 2026-09-11)
Aetna's Clinical Policy Bulletin 0586 sets medical necessity criteria for heart transplantation and related services. Heart transplant is considered medically necessary for the listed indications, including cardiomyopathy, end-stage ventricular failure and congenital heart disease, when the member meets the transplanting institution's protocol eligibility criteria, and off protocol when all listed selection criteria are met. The policy also covers the FDA-approved total artificial heart as a bridge to transplant, AlloMap testing for rejection monitoring more than 2 months after transplant, and ex vivo heart perfusion for preservation and transport of the donor heart, and it lists several rejection tests and other procedures as experimental, investigational or unproven.
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 Sep 30, 2026Medium impact
Pancreas Kidney Transplantation (CPB 0587, reviewed 2026-09-08)
Aetna's Clinical Policy Bulletin 0587 considers simultaneous pancreas-kidney (SPK) transplantation and simultaneous cadaver-donor pancreas and living-donor kidney (SPLK) transplantation medically necessary for members with diabetes and end-stage renal disease (ESRD) who meet the transplanting institution's selection criteria. Where an institution has no selection criteria, Aetna requires an estimated glomerular filtration rate (eGFR) of 20 mL/min/1.73 m² or less and ESRD that requires dialysis or is expected to require dialysis in the next 12 months. Relative contraindications include chronic liver disease, severe cerebrovascular or peripheral vascular disease, uncontrolled or untreated psychiatric disorders that interfere with compliance, a BMI of 35 or higher with type 2 diabetes, structural genito-urinary abnormality or recurrent urinary tract infection, treated malignancy, and uncontrolled hypertension. SPK and SPLK may still be performed for persons with these relative contraindications when the attending physician determines and documents that the potential benefits outweigh the risks. Aetna considers SPK and SPLK not medically necessary for poorly controlled HIV infection and for absolute contraindications, including homelessness, active substance abuse, unstable psychiatric disease, malignancy with significant risk of recurrence, ongoing or recurrent active infections that are not adequately treated, and severe uncorrectable cardiac disease. Aetna considers the Georges Lopez Institute preservation solution (IGL-1) and measurement of donor-derived cell-free DNA for monitoring rejection experimental, investigational, or unproven.
Aetna · Identified Aug 19, 2026Medium impact
Intermittent Pneumatic Compression Devices (CPB 0500, reviewed 2026-07-10)
Aetna considers full-leg or half-leg home-use pneumatic compression devices medically necessary durable medical equipment for chronic venous insufficiency of the legs in members with venous stasis ulcers that have failed to heal after a 6-month trial of conservative therapy directed by the treating physician. Intermittent pneumatic compression devices for the lower extremities are considered medically necessary for members who are bedridden due to trauma, orthopedic surgery, neurosurgery or other circumstances preventing ambulation, and a single patient use device is considered not medically necessary. Aetna lists other uses as experimental, investigational or unproven, including treatment of critical limb ischemia, intermittent claudication, post-thrombotic syndrome, restless legs syndrome and intra-operative compression for reduction of venous thromboembolism in craniotomy.
Aetna · Identified Aug 19, 2026Medium impact
Kidney Transplantation (CPB 0493, reviewed 2026-07-30)
Aetna considers kidney transplantation medically necessary for members who meet the transplanting institution's selection criteria. Where no institution criteria apply, the member must complete an evaluation and be accepted by the kidney transplant committee, meet the transplanting institution's protocol age criteria, have no malignancy except the listed exceptions, and meet the policy's infection, cardiovascular, pulmonary, hepatic and severity-of-disease criteria. Aetna considers belatacept (Nulojix) medically necessary for preventing acute rejection in kidney transplant recipients who are sero-positive for Epstein-Barr virus, and equine anti-thymocyte globulin (Atgam) medically necessary for prophylaxis or treatment of allograft rejection in renal transplantation in combination with conventional therapy, and for moderate to severe aplastic anemia in persons who are not suitable candidates for bone marrow transplantation, while gene microarray, donor-derived cell-free DNA, urinary biomarker, TruGraf and AI/ML graft survival tests are experimental, investigational, or unproven for the indications listed.
Aetna · Identified Aug 18, 2026Medium impact
Thrombectomy Systems (CPB 0568, reviewed 2025-08-26)
Aetna considers the AngioJet Rheolytic Thrombectomy System medically necessary for removing fresh blood clots from arteriovenous fistulas used for hemodialysis, from coronary arteries or coronary bypass grafts at least 2.0 mm in diameter before angioplasty or stent placement, from infra-inguinal peripheral arteries at least 2.0 mm in diameter, and in individuals with lower extremity deep vein thrombosis who have failed pharmacologic thrombolysis or in whom pharmacologic thrombolysis is contraindicated. Thrombectomy systems are considered experimental, investigational or unproven for acute aortic occlusion, acute renal artery thrombosis, cerebral venous sinus thrombosis, inferior vena cava filter-related thrombosis, May-Thurner syndrome-related deep venous thrombosis, pulmonary embolism, and thrombosis of the native aortic valve and of the left ventricular assist device in heart failure. The ClotHunter for lower extremity deep vein thrombosis and mechanical thrombectomy or thrombo-aspiration for acute ilio-femoral deep vein thrombosis are also considered experimental, investigational or unproven.
Aetna · Identified Aug 18, 2026Medium impact
Nutritional Support (CPB 0061, reviewed 2026-01-15)
Aetna considers nutritional support a medical item only when it is given by feeding tube or intravenously to a member with permanent non-function or disease of the structures that normally permit food to reach the small bowel, or with small bowel disease that impairs digestion and absorption of an oral diet, and when adequate nutrition cannot be met by dietary adjustment or oral supplements. Aetna does not cover nutritional support taken orally unless state law mandates it, and it does not cover banked breast milk, food supplements, specialized infant formulas, or vitamins and minerals taken orally. Parenteral nutrition is considered medically necessary when adequate intake is not possible by oral or tube feeding, such as after documented enteral failure, when the gastrointestinal tract must be totally non-functioning for a period of time, or when structural or functional bowel disease makes oral and tube feedings inappropriate.
Aetna · Identified Aug 16, 2026Medium impact
Intravenous Iron Therapy (CPB 0575, reviewed 2026-07-01)
Feraheme, Ferrlecit, Injectafer, Monoferric and Venofer are medically necessary only for commercial members who have a contraindication, intolerance or ineffective response to the lower cost alternatives generic ferumoxytol, generic iron sucrose, generic sodium ferric gluconate and INFeD (iron dextran) for the labeled indication. Precertification is required for Feraheme, Ferrlecit, generic sodium ferric gluconate, Injectafer, Monoferric, Venofer and generic iron sucrose in applicable plan designs. Intravenous iron is considered experimental, investigational or unproven for other indications, including acute mountain sickness and anemia of inflammation, and it is contraindicated for genetic hemochromatosis or hemochromatosis secondary to iron overload.
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.
Aetna · Identified Aug 13, 2026Medium impact
Pancreas Kidney Transplantation (CPB 0587, reviewed 2025-09-10)
Aetna considers simultaneous pancreas-kidney (SPK) and simultaneous cadaver-donor pancreas and living-donor kidney (SPLK) transplantation medically necessary for members with diabetes and end-stage renal disease who meet the transplanting institution's selection criteria, or, without institution criteria, when eGFR is less than or equal to 20 mL/min/1.73 m² and the member has ESRD that requires dialysis or is expected to require dialysis within 12 months. Relative contraindications, including chronic liver disease, uncontrolled hypertension, and BMI of 35 or higher with type 2 diabetes, are allowed when the attending physician determines and documents that the potential benefits outweigh the risks. Aetna considers SPK and SPLK not medically necessary for poorly controlled HIV and for absolute contraindications, and considers the IGL-1 preservation solution and donor-derived cell-free DNA monitoring for rejection experimental, investigational, or unproven. The policy was last reviewed 09/08/2026 and its next review is 06/24/2027.
Aetna · Identified Aug 12, 2026Medium impact
Calcitriol, Etelcalcetide, and Paricalcitol Injections (CPB 0022, reviewed 2026-02-11)
Aetna considers calcitriol, etelcalcetide (Parsabiv) and paricalcitol (Zemplar) injections medically necessary for commercial medical plans only for the listed indications in members with chronic kidney disease on hemodialysis. Each of these medications must be prescribed by or in consultation with an endocrinologist or a nephrologist. Etelcalcetide is medically necessary only for members with a contraindication, intolerance or ineffective trial of the equivalent alternatives, and continuation is medically necessary when the member shows benefit from therapy.
Aetna · Identified Aug 12, 2026Medium impact
Analysis of Volatile Organic Compounds (CPB 0717, reviewed 2025-11-25)
Aetna considers the analysis of volatile organic compounds (VOCs) experimental, investigational or unproven for the listed indications, because the clinical effectiveness of this technique has not been established. The listed indications include detection of bacteriuria, detection of cancer, diagnosis of pneumonia, diagnosis of tuberculosis, diagnosis of lung disease (e.g., asthma), diagnosis of obstructive sleep apnea, and screening for COVID-19. The list is not all-inclusive.
Presbyterian Health Plan · Identified Jul 31, 2026Medium impact
2026 July Network Connection
CPT 90785 (interactive complexity) may be billed only as an add-on code that accompanies an eligible primary psychiatric service, and only when its specific criteria and requirements are met. Medical records must clearly support CPT 90785 by describing specific communication challenges, challenges affecting clinical interaction, the interactive methods used, and why standard communication approaches were insufficient, and claims submitted without adequate documentation may be subject to audit or review with payment adjusted if billing requirements are not met. Nail pathogen panel claims should be supported by clear clinical indication and medical necessity, prior testing and treatment history, a valid signed provider order specifying test type, and accurate diagnosis coding, and the Presbyterian Program Integrity Department performs random claims validation audits.
Medical Mutual of Ohio · Identified Jun 20, 2026Medium impact
HEDIS Advanced Illness and Frailty Exclusion
Medical Mutual of Ohio has implemented HEDIS exclusion guidelines for advanced illness and frailty patients. Billing teams must use specific ICD-10 codes to exclude eligible patients (ages 66-80 with both conditions, or 81+ with frailty) from certain HEDIS quality measures like cancer screenings and diabetes management.
Healthfirst · Identified Jun 20, 2026Medium impact
June is Myasthenia Gravis Awareness Month: Documentation and Coding Resources for Your Practice
Healthfirst released updated documentation and coding guidelines for Myasthenia Gravis in recognition of awareness month. The policy provides specific ICD-10-CM codes, documentation requirements, and coding tips to ensure accurate billing and proper clinical documentation for this rare autoimmune neuromuscular condition.
Florida Blue · Identified Jun 16, 2026Medium impact
Coding Newsletter - Chronic Kidney Disease
Florida Blue has updated coding guidelines for Chronic Kidney Disease (CKD), emphasizing the requirement for providers to document specific CKD stages (1-5 or ESRD) and underlying causes. The policy clarifies ICD-10-CM code mapping for each CKD stage and establishes documentation requirements for combination coding with diabetes and hypertension.
Florida Blue · Identified Jun 16, 2026Medium impact
Florida Blue Medicare Risk Adjustment Best Practices and Coding Educational Guide, 2023
For Medicare Advantage risk adjustment under the CMS-HCC models V24 and V28, diagnoses must be supported by clear, specific medical record documentation. Chronic conditions must be reported once a year to maintain the patient's HCC risk score, and key status conditions such as amputation or transplant status must also be reported each year. Documentation rules are set out for chronic conditions including chronic kidney disease, diabetes, heart failure, COPD, cancer, major depression and substance use disorders.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect code N18.6?

There are 24 tracked policy changes affecting code N18.6, including updates from Horizon BCBS NJ, Independence Blue Cross, Capital Blue Cross. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for code N18.6?

Payers that have issued tracked updates for code N18.6 include: Horizon BCBS NJ, Independence Blue Cross, Capital Blue Cross, Aetna, Presbyterian Health Plan, Medical Mutual of Ohio, Healthfirst, Florida Blue.

How do I get notified when code N18.6 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to code N18.6. 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 code N18.6?

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.

All billing codes J3590 C9399 J3490 99215 99213 99202

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Statin Use in Persons with Diabetes (SUPD)

MA08.011i, Erythropoiesis Stimulating Agents (ESAs)

08.00.75r, Erythropoiesis-Stimulating Agents (ESAs)

AB2026-04-002 Medicare only

Selected Kidney Function Tests (CPB 0775, reviewed 2026-10-28)

Analysis of Volatile Organic Compounds (CPB 0717, reviewed 2026-10-20)

Thrombectomy Systems (CPB 0568, reviewed 2026-09-18)

Heart Transplantation (CPB 0586, reviewed 2026-09-11)

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

Pancreas Kidney Transplantation (CPB 0587, reviewed 2026-09-08)

Intermittent Pneumatic Compression Devices (CPB 0500, reviewed 2026-07-10)

Kidney Transplantation (CPB 0493, reviewed 2026-07-30)

Thrombectomy Systems (CPB 0568, reviewed 2025-08-26)

Nutritional Support (CPB 0061, reviewed 2026-01-15)

Intravenous Iron Therapy (CPB 0575, reviewed 2026-07-01)

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

Pancreas Kidney Transplantation (CPB 0587, reviewed 2025-09-10)

Calcitriol, Etelcalcetide, and Paricalcitol Injections (CPB 0022, reviewed 2026-02-11)

Analysis of Volatile Organic Compounds (CPB 0717, reviewed 2025-11-25)

2026 July Network Connection

HEDIS Advanced Illness and Frailty Exclusion

June is Myasthenia Gravis Awareness Month: Documentation and Coding Resources for Your Practice

Coding Newsletter - Chronic Kidney Disease

Florida Blue Medicare Risk Adjustment Best Practices and Coding Educational Guide, 2023

What insurance policy changes affect code N18.6?

Which payers have updated policy for code N18.6?

How do I get notified when code N18.6 policy changes?

Why do payers change policies for code N18.6?