Response to Comments: Frequency of Hemodialysis

This article summarizes the comments WPS received for Draft Local Coverage Determinations (LCD) Frequency of Hemodialysis (L37537). Thank you for the comments. WPS GHA received numerous comments related to DL37537. This present draft form is an expansion of the coverage diagnoses, addition of the use of a modifier to identify those additional treatments needed, and establishes an appropriate way to have appeals available should a denial occur for those diagnoses not in the list. As noted in the document, the draft addresses a narrow issue for the ESRD program and does not change the base payment process issued by CMS. CMS charged Local Contractors (MACs) to develop a list of clinical conditions appropriate for payment beyond the thrice weekly payment by CMS. This list (included in the draft) is felt to be appropriate for such payments should medical documentation be supportive. All payment policies for ESRD program reside with CMS for other changes. MACs do not have the jurisdiction to change any basic payment policies related to this issue and is only defining a list of clinical conditions that up front in the submission of a claim could be felt to be appropriate for additional payment should medical documentation support use if reviewed. There will be other clinical situations that may require additional treatments. These lines in the claims, even though they do not have a diagnosis listed, can be noted by an appended KX modifier (see A55703). They would need additional review following an initial denial. In the comment review, all submitted published literature was reviewed. WPS GHA does not do research based on bibliographies that may have been submitted along with comments. Many of the issues were similar and gathering of like comments was done for a response. A large number of literature articles were submitted by industry that encompasses the requests from others who did not submit literature. In general, the comments address home dialysis and more frequent dialysis as a baseline for payment. This issue is outside the scope of the draft LCD and will need to be addressed by CMS. MACs do not have in their jurisdictions the mandate to change baselines payment strategies for CMS. The comments can generally be divided into three categories: Patient, caretakers, those who work with these patients Providers and societies/organizations Industry