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

Immediately effective from 2025-11-26: (1) Billing team must update claim submission logic to ensure hemodialysis procedure codes (90935, 90937) are only billed when frequency meets medical necessity criteria (up to 3x weekly or more for documented qualifying conditions: hyperkalemia, hypophosphatemia, pregnancy, fluid overload, acute pericarditis, CHF, pulmonary edema, severe catabolic state). (2) Update authorization and billing systems to verify that experimental/non-covered codes are not processed: do NOT bill for bioengineered vessels, vitamin E-coated membranes (no specific code), EchoSure systems, IL-6 levels (83529), or wearable hemodialysis devices. (3) For home hemodialysis claims: verify CPT 99512 is supported by documentation showing skilled nursing visits per physician care plan AND that member meets criteria (stable on dialysis per NKF standards, good vascular access, medical contraindications to clinic dialysis, inability to self-manage post-training). (4) HCPCS supply codes (A4216-A4737): implement system edits to reject claims for backup equipment, spare deionizing tanks (A-code for deionizing supplies), ultrafiltration monitors independent of hemodialysis, and Peridex filter sets for peritoneal dialysis. (5) For percutaneous AV fistula creation (CPT 36836, 36837): ensure these are recognized as covered alternatives to surgical fistula creation; verify angioplasty with FDA-approved balloons is supported. (6) Implement one-time allowance logic: flag emergency reserve supplies as covered only up to 1 month quantity on initial dialysis initiation. (7) Update denial logic: reject repair/maintenance charges on rented equipment (included in rental fees). Contact Aetna's clinical team if documentation shows member does not meet criteria for higher-frequency dialysis or experimental technologies. Failure to implement these rules will result in claim denials and payment recoupment.