Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: E-2-024
Topic: Home Dialysis Equipment and Supplies
Section: Durable Medical Equipment
Effective Date: August 13, 2018
Issue Date: August 13, 2018
Last Reviewed: July 2018

Home dialysis equipment is all equipment, supplies and support services, and certain drugs and biologicals which are required to effectively perform dialysis in the home. This includes instruments and non-medical supplies [e.g., scales, blood pressure cuffs, stop watches, stethoscope, heating pad for peritoneal dialysis, etc.] and disposable supplies [e.g., alcohol wipes, sterile drapes, etc.]

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

Home use of dialysis equipment, supplies, and selected medications may be considered medically necessary when the individual has a diagnosis of end-stage renal disease (ESRD). 

All other uses of home dialysis equipment, supplies and selected medications will be considered not medically necessary.

Procedure Codes
A4245, A4651, A4652, A4653, A4657, A4660, A4663, A4670, A4671, A4672, A4673, A4674, A4680, A4690, A4706, A4707, A4708, A4709, A4714, A4719, A4720, A4721, A4722, A4723, A4724, A4725, A4726, A4728, A4730, A4736, A4737, A4740, A4750, A4755, A4760, A4765, A4766, A4770, A4771, A4772, A4773, A4774, A4802, A4860, A4870, A4911, A4913, A4918, A4927, A4928, A4929, E0210, E1500, E1510, E1520, E1530, E1540, E1550, E1560, E1570, E1575, E1580, E1590, E1592, E1594, E1600, E1610, E1615, E1620, E1625, E1630, E1632, E1634, E1635, E1636, E1637, E1639, E1699, J1644, S9007

An exception to the general coverage of all dialysis supplies is the “Patient Aid,” a device used to train dialysis patients in correcting alarm conditions.  These devices are considered not medically necessary.

The instruments and non-medical supplies must either be purchased or provided as part of the actual dialysis equipment and included in the overall charge for such equipment. (Coverage does not extend to the rental of these items separately. Claims submitted for rental of the instruments/non-medical equipment (as separate units) will be denied. Disposable supplies are covered as separate items.)

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.

For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Shipping charges for home dialysis supplies are covered.

See Medical Policy Bulletin E-1 for guidelines on Thermometers.

Place of Service: Outpatient

Home dialysis equipment and supplies are typically used on an outpatient basis which are only eligible for coverage on an inpatient basis in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business

Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.


Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

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