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Printer Friendly Version Continuous Arteriovenous Hemofiltration

Continuous Arteriovenous Hemofiltration

DESCRIPTION

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.

POLICY

Continuous renal replacement therapy may be considered medically necessary as a supportive treatment for acute renal failure.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

POLICY HISTORY

9/1994: 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.

SOURCE(S)

Uniform Medical Policy Manual

Technology Evaluation and Coverage: 1986: p. 69

Blue Cross Blue Shield Association policy #8.02.01

CODE REFERENCE

This is not intended to be a comprehensive list of codes. Some codes may be variable and coverage will be based on the clinical indication for the service.

Covered Codes

*Some covered procedure codes have multiple descriptions. Coverage will only be made for covered codes when used fro services outlined within the policy statement section.

Code Number	Description
CPT-4
90945	Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies), with single physician evaluation (description revised 8-11-2005)
90947	Dialysis procedure other than hemodialysis (eg, peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies) requiring repeated physician evaluations, with or without substantial revision of dialysis prescription (description revised 8-11-2005)
ICD-9 Procedure
39.95	Hemodialysis (includes hemofiltration)
ICD-9 Diagnosis
404.02	Hypertensive heart and chronic kidney disease, malignant, without heart failure and without chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
404.03	Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
404.12	Hypertensive heart and chronic kidney disease, benign, without heart failure and without chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
404.13	Hypertensive heart and chronic kidney disease, benign, with heart failure and without chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
404.92	Hypertensive heart and chronic kidney disease, unspecified, without heart failure and without chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
404.93	Hypertensive heart and chronic kidney disease, unspecified, with heart failure and without chronic kidney disease stage V or end stage renal disease (Description revised 10-1-2006)
581.9	Nephrotic syndrome with unspecified pathological lesion in kidney (description revised 8-11-2005)
584.5	Acute kidney failure with lesion of tubular necrosis (description revised 10-1-2009)
584.6	Acute kidney failure with lesion of renal cortical necrosis (description revised 10-1-2009)
584.7	Acute kidney failure with lesion of renal medullary [papillary] necrosis (description revised 10-1-2009)
584.8	Acute kidney failure with other specified pathological lesion in kidney (description revised 10-1-2009)
584.9	Acute kidney failure, unspecified (description revised 10-1-2009)
585.1, 585.2, 585.3, 585.4, 585.5, 585.6, 585.9	Chronic kidney disease code range (4th digits and revised description effective 10/1/2005) (added 11/8/2005)
586	Renal failure, unspecified
639.3	Kidney failure following abortion and ectopic and molar pregnancies (description revised 10-1-2009)
669.3	Acute renal failure following labor and delivery
958.5	Traumatic anuria (renal failure following crushing) (description revised 8-11-2005)
HCPCS
A4300	Implantable access catheter, (e.g., venous, arterial, epidural subarachnoid, or peritoneal, etc.) external access (description revised 8-11-2005)
A4651, A4652, A4653, A4656, A4657, 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, A4911, A4913, A4918	Dialysis supplies code range ( A4656 deleted 12-31-2005)
E1510, E1592, E1594, E1600, E1610, E1615, E1620, E1625, E1630, E1632, E1634, E1635, E1636, E1637, E1639, E1699	Dialysis equipment code range

Non-Covered Codes

*This is not an all inclusive list of non-covered procedure codes.

Code Number	Description
CPT-4

ICD-9 Procedure

ICD-9 Diagnosis

HCPCS
A4660, A4663, A4670, A4870, A4890, A4927	Dialysis supplies code range (moved to non-covered 8-11-2005)
E1520, E1530, E1540, E1550, E1560, E1570, E1575, E1580, E1590	Dialysis equipment code range (moved to non-covered 8-11-2005)

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