HI 00610.310 Treatment of End-Stage Renal Disease

A. End-Stage Renal Disease (ESRD)

The term end-stage renal disease (ESRD) is used with the understanding that in this context the reference is to end-stage renal disease which requires dialysis or transplanation, as set out in the law. In correspondence with the public, it is recommended that a term such as “permanent kidney failure” be used, or “end-stage renal disease,” with the qualifying language of the law.

B. Dialysis

A process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semipermeable membrane. There are two types of renal dialysis in common clinical usage, hemodialysis and peritoneal dialysis. Both hemodialysis and peritoneal dialysis are acceptable modes of treatment of chronic renal disease.

1. Hemodialysis

Where blood is passed through an artificial kidney machine and the waste products diffuse across a man-made membrane into a bath solution known as dialysate after which the cleansed blood is returned to the patient's body.

2. Peritoneal dialysis

Where the waste products pass from the patient's body through the peritoneal membrane into the peritoneal (abdominal) cavity where the bath solution (dialysate) is introduced and removed periodically.

3. Continuous Ambulatory Peritoneal Dialysis (CAPD)

Continuous ambulatory peritoneal dialysis is a variation of peritoneal dialysis that was developed as an alternative mode of dialysis for home dialysis patients. CAPD is a continuous dialysis process that uses the patient's peritoneal membrane as a dialyzer. The patient connects a 2 liter plastic bag of dialysate to a surgically implanted indwelling catheter and allows the dialysate to pour into the peritoneal cavity. Four to six hours later the patient drains the fluid out into the same bag, and replaces the old bag with a new bag of fresh dialysate. This procedure is performed three to five times a day with the first exchange being made when the patient wakes up in the morning, and the last exchange being made at bed time. No machine is used.

C. Maintenance dialysis

The usual periodic dialysis treatments which are given to a patient who has ESRD in order to sustain life and ameliorate uremic symptoms. Maintenance hemodialysis is generally required two to three times per week and peritoneal dialysis once per week, but less frequent treatments are sometimes adequate. In addition, greater frequency may be covered upon review of evidence which establishes medical necessity.

D. Acute dialysis

Dialysis given to patients who require inpatient care. (Acute dialysis may also be given to patients without ESRD because of temporary renal failure due to, for example, ingestion of certain drugs. Such conditions and treatment are not a basis for coverage under the ESRD provision.)

E. Self-dialysis

Regular maintenance dialysis performed by a trained patient at home or within an outpatient facility. In the case of home dialysis the patient performs dialysis with the assistance of a trained partner. In the case of “self-care” dialysis in an outpatient facility, the patient performs dialysis in a facility removed from the home, with the minimal assistance of an aide.

F. Back-up dialysis

Dialysis given to patients under special circumstances, in a situation other than the patients' usual dialysis environment. Examples are dialysis of a home dialysis patient in a limited care unit when his equipment fails, inpatient dialysis when patient illness requires more comprehensive care on an inpatient basis, and pre- and postoperative dialysis provided to transplant patients.

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HI 00610.310 - Treatment of End-Stage Renal Disease - 07/14/2014
Batch run: 07/14/2014