PA Lookup

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.

Limits

Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.

For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.

Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.

Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.

If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.

Hemodialysis training is reimbursed in sessions that can last up to five hours per day.

Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.

CAPD and CCPD are covered per date of service, not per treatment.

Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.

Dialysis training is typically completed within two weeks of initiating self-care.

CAPD training sessions can last up to eight hours per day.

CCPD training sessions can last up to eight hours per day.

Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.

Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.

Little or no professional assistance is provided except in an emergency.

Dialysis training is typically completed within two weeks of initiating self-care.

Hemodialysis training sessions can last up to 5 hours per day.

Reimbursement for the completed course is allowed once per beneficiary's lifetime.

Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.

Training and retraining sessions are reimbursed at the same rate.

Exclusions

Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.

For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.

Medicaid shall not cover the following Dialysis Services:

• a. office visits, home visits, consults and care plan oversight included in the

monthly capitation;

• b. access maintenance performed by the staff in the ESRD facility;
• c. take home drugs and supplies;
• d. specimen collection fees;
• e. transportation: The beneficiary is encouraged to contact their local county

Department of Social Services for assistance;

• f. medical supply charges, including syringes and their administration;
• g. costs associated with a private caregiver, outside of allowed training paid to

the training facility; and

• h. capitation payment for the month in which the training code is billed.

Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.

Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.

Place of Service

Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1A-34
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

How to Submit

Please submit your request to Trillium Health Resources

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

The term “allergy” indicates an abnormally hypersensitive immune reaction in response to exposure to certain foreign substances. Allergy-producing substances are called "allergens.” When an allergic individual comes in contact with an allergen, the immune system mounts a response through the immunoglobulin E ( IgE ) antibody.

Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as by localized reactions in any organ system of the body. The reaction may be acute, subacute, or chronic, immediate, or delayed and may be caused by numerous offending agents including pollen, molds, foods, and drugs.

The management of an allergy or hypersensitivity may include identifying the offending substance (allergen) by means of various testing methods. Immunoglobulin E (IgE)-mediated allergy testing is evaluated by measuring allergen-specific IgE. This can be done through skin testing (in vivo) testing or with serological tests (in vitro). Allergy testing includes the performance, evaluation, and reading of the tests.

It is important to note that skin prick tests, and tests that measure total serum levels of IgE or allergen-specific IgE, only detect the presence of allergic sensitization. They do not, by themselves, make a diagnosis of allergy. For instance, almost one-half of the U.S. population has detectable allergen-specific IgE against a food allergen, but the overall prevalence of clinical food allergy is only about 4 to 6 percent.

Treatment options for allergies are avoidance of allergen, pharmacological therapy, and immunotherapy.

Authorization Guidelines

Services are provided by a physician or qualified non-physician practitioner after ALL the following are completed;

• 1. Completes a medical and immunologic history, along with a physical exam;
• 2. Determines, upon completion of the history and physical exam, one of the following:
• A. that signs and symptoms are suggestive of an allergy: or
• B. a diagnosis indicates an allergy, such as asthma.
• 3. Establishes reasonable probability of exposure in the beneficiary’s environment;
• 4. Documents in the health record that symptoms are not controllable by empiric conservative therapy;
• 5. Documents in the health record all tried and failed allergy treatments;
• 6. Selects the appropriate allergy test with proven efficacy published in peer-reviewed literature; and
• 7. Orders the allergy test based on findings from (1) through (6) above that document and appropriately support the antigen being used for testing.

Limits

• 1. Billing unit limit: for CPT 86003, each specific allergen tested must be billed as one unit.
• 2. Specific IgE tests may be performed by a clinical laboratory.

Length of Stay

30 units per 365 calendar days

Exclusions

• 1. The policy also excludes investigational allergy tests, specifically leukocyte histamine release, Rebuck skin window, Prausnitz-Kustner test, cytotoxic food testing, conjunctival challenge testing, nasal challenge test, kinesiology testing, provocation-neutralization testing, and electrodermal testing.

Diagnosis Requirements

Specific IgE in vitro testing is covered only after the general allergy testing criteria are met. Services must be provided by a physician or qualified non-physician practitioner after completing a medical and immunologic history and physical exam. Based on that evaluation, the practitioner must determine that signs and symptoms are suggestive of an allergy or that the diagnosis indicates an allergy, such as asthma. The practitioner must establish a reasonable probability of exposure in the beneficiary's environment, document that symptoms are not controllable by empiric conservative therapy, document all tried and failed allergy treatments, select the appropriate allergy test with proven efficacy published in peer-reviewed literature, and order the test based on findings that document and appropriately support the antigen being used for testing. Specific IgE in vitro tests are covered for inhalant allergens including pollens, molds, dust mites, and animal dander, as well as foods, insect stings, and drugs. Policy-wide, the service must also be medically necessary, individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis, safely furnished, and not primarily for convenience.

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

• 1N-1, Allergy Testing
• Records Management and Documentation Manual

The term “allergy” indicates an abnormally hypersensitive immune reaction in response to exposure to certain foreign substances. Allergy-producing substances are called "allergens.” When an allergic individual comes in contact with an allergen, the immune system mounts a response through the immunoglobulin E ( IgE ) antibody.

Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as by localized reactions in any organ system of the body. The reaction may be acute, subacute, or chronic, immediate, or delayed and may be caused by numerous offending agents including pollen, molds, foods, and drugs.

The management of an allergy or hypersensitivity may include identifying the offending substance (allergen) by means of various testing methods. Immunoglobulin E (IgE)-mediated allergy testing is evaluated by measuring allergen-specific IgE. This can be done through skin testing (in vivo) testing or with serological tests (in vitro). Allergy testing includes the performance, evaluation, and reading of the tests.

It is important to note that skin prick tests, and tests that measure total serum levels of IgE or allergen-specific IgE, only detect the presence of allergic sensitization. They do not, by themselves, make a diagnosis of allergy. For instance, almost one-half of the U.S. population has detectable allergen-specific IgE against a food allergen, but the overall prevalence of clinical food allergy is only about 4 to 6 percent.

Treatment options for allergies are avoidance of allergen, pharmacological therapy, and immunotherapy.

Authorization Guidelines

Services are provided by a physician or qualified non-physician practitioner after ALL the following are completed;

• 1. Completes a medical and immunologic history, along with a physical exam;
• 2. Determines, upon completion of the history and physical exam, one of the following:
• A. that signs and symptoms are suggestive of an allergy: or
• B. a diagnosis indicates an allergy, such as asthma.
• 3. Establishes reasonable probability of exposure in the beneficiary’s environment;
• 4. Documents in the health record that symptoms are not controllable by empiric conservative therapy;
• 5. Documents in the health record all tried and failed allergy treatments;
• 6. Selects the appropriate allergy test with proven efficacy published in peer-reviewed literature; and
• 7. Orders the allergy test based on findings from (1) through (6) above that document and appropriately support the antigen being used for testing.

Unit Value

Each antigen tested (one test) must be billed as one unit, even if more than one injection or scratch or prick of the antigen is used on the same day.

Limits

Specific IgE tests may be performed by a clinical laboratory.

Length of Stay

2 units per day up to 30 allergens per 365 calendar days

Exclusions

• 1. The policy also excludes investigational allergy tests, specifically leukocyte histamine release, Rebuck skin window, Prausnitz-Kustner test, cytotoxic food testing, conjunctival challenge testing, nasal challenge test, kinesiology testing, provocation-neutralization testing, and electrodermal testing.

Diagnosis Requirements

Specific IgE in vitro testing is covered only after the general allergy testing criteria are met. Services must be provided by a physician or qualified non-physician practitioner after completing a medical and immunologic history and physical exam. Based on that evaluation, the practitioner must determine that signs and symptoms are suggestive of an allergy or that the diagnosis indicates an allergy, such as asthma. The practitioner must establish a reasonable probability of exposure in the beneficiary's environment, document that symptoms are not controllable by empiric conservative therapy, document all tried and failed allergy treatments, select the appropriate allergy test with proven efficacy published in peer-reviewed literature, and order the test based on findings that document and appropriately support the antigen being used for testing. Specific IgE in vitro tests are covered for inhalant allergens including pollens, molds, dust mites, and animal dander, as well as foods, insect stings, and drugs. Policy-wide, the service must also be medically necessary, individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis, safely furnished, and not primarily for convenience.

Place of Service

Outpatient, Office

How to Submit

N/A - No authorization is required

Resources

• 1N-1, Allergy Testing
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required