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Continuous arteriovenous hemofiltration (CAVH) is an extracorporeal renal replacement therapy (i.e., treatment which supplements kidney function). The device is powered, in most cases, by the patient's own arterial pressure. Blood is propelled through a semipermeable membrane which permits extraction of fluids, electrolytes, and other molecules of low molecular weight and is returned to the patient via the venous access.
POLICYContinuous renal replacement therapy may be considered medically necessary as a supportive treatment for acute renal failure.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY9/1994: Approved by Medical Policy Advisory Committee (MPAC)
4/18/2002: Type of Service and Place of Service deleted
8/11/2005: Code Reference section updated, CPT code 90945, 90947 description revised, ICD-9 diagnosis code 581.9, 958.5 description revised, HCPCS A4300 description revised, HCPCS A4650 deleted, non-covered table added, HCPCS A4660, A4663, A4670, A4870, A4890, A4927, E1520, E1530, E1540, E1550, E1560, E1570, E1575, E1580, E1590 moved to non-covered
11/8/05: Code Reference section updated, 4th digit added to ICD9 diagnosis codes 585.1-585.9; description revised
3/13/2006: Coding updated. HCPCS 2006 revisions added to policy
3/20/2006: Policy reviewed, no changes
09/13/2006: Coding updated. ICD9 2006 revisions added to policy.
9/29/2009: Code reference section updated. Description revised for ICD-9 diagnosis codes 584.5-584.9, and 639.3.
08/25/2015: Code Reference section updated for ICD-10. Removed deleted HCPCS code A4656. Removed HCPCS code A4670 from the Not Medically Necessary Codes table. Extended ICD-9 diagnosis code 669.3 to the fifth digit (669.30, 669.32, 669.34).
SOURCE(S)Uniform Medical Policy Manual
Technology Evaluation and Coverage: 1986: p. 69
Blue Cross Blue Shield Association policy #8.02.01
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
Not Medically Necessary Codes