Continuous Arteriovenous Hemofiltration

POLICY NUMBER

L.8.02.400

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.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

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.

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).

03/20/2017: Policy number L.8.02.400 added. Policy Guidelines updated to add medically necessary definition.

09/29/2017: Code Reference section updated regarding deleted ICD-10 procedure codes.

09/30/2020: Code Reference section updated to add new ICD-10 diagnosis codes N18.30, N18.31, and N18.32, effective 10/01/2020. Removed deleted ICD-10 procedure codes 5A1D00Z, 5A1D60Z, and related ICD-9 procedure code 39.95.

10/10/2022: Policy reviewed. Policy statement unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity."

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes O90.41 and O90.49, effective 10/01/2023.

10/17/2023: Policy reviewed; no changes.

11/07/2024: Policy reviewed. Policy statement unchanged. Code Reference section updated to remove deleted ICD-10 diagnosis code O90.4.

SOURCE(S)

1. Blue Cross Blue Shield Association policy #8.02.01

2. Technology Evaluation and Coverage: 1986: p.69

3. Uniform Medical Policy Manual

CODE REFERENCE

This 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.

Covered Codes 

Not Medically Necessary Codes

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