Dialysis Access Maintenance

LCD Information Document Information Source LCD ID N/A LCD ID L34062 Original ICD-9 LCD ID Not Applicable LCD Title Dialysis Access Maintenance Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/22/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. 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Issue Issue Description This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity. Issue - Explanation of Change Between Proposed LCD and Final LCD CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. CMS Publications:CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 11: End Stage Renal Disease (ESRD): 20.1 Noninvasive Vascular Studies for End Stage Renal Disease (ESRD) Patients 30.4.2 Separately Billable Drugs. 30.5 ESRD Composite Payment Rates 80 Physician’s Services for Renal Dialysis Patients - General CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 14: Medical Devices: 10 Coverage of Medical Devices 20 FDA Approval Investigational Device Exemptions (IDEs) 20.2 - Category B CMS Publication 100-03, Medicare National Coverage Determinations Manual, Part 1: 20.7.B1 Percutaneous Transluminal Angioplasty (PTA)20.7.D Other CMS Publication 100-09, Medicare Contactor Beneficiary and Provider Communications Manual, Chapter 5: Correct Coding Initiative.CMS Transmittal AB-00-44, Change Request #1118, May 2000: Medicare Coverage of Non-Invasive Vascular Studies When Used to Monitor the Access Site of End Stage Renal Disease (ESRD) Patients.CMS Transmittal AB-00-55, Change Request #1117, June 2000: Hemodialysis Flow Study. Coverage Indications, Limitations, and/or Medical Necessity Arteriovenous (AV) dialysis access (AV fistula, AV dialysis graft) interventions are intended to restore and/or maintain functional patency of the AV dialysis access. These procedures encompass a number of percutaneous or open surgical procedures. Indications for interventions on an AV dialysis access include compromised flow with threatened occlusion, recent thrombosis of AV dialysis access, and management of structural abnormalities such as pseudoaneurysms. Interventions are performed on AV dialysis fistulas and grafts in order to restore adequate flow, to preserve the access' function, and avoid the need to create a new AV access. Fistulae which are not maturing as expected are also evaluated and treated with percutaneous interventions.Percutaneous interventions to enhance or re-establish patency of a hemodialysis AV access have proven useful in extending the life of the access, reducing the need for open repair, reconstruction or replacement. The longevity and quality of life of the end stage renal dialysis (ESRD) patient are improved. This policy documents acceptable indications and limitations of coverage and other CGS requirements for dialysis access maintenance services. Definitions: (AV) dialysis access: A surgically-created communication between an artery and a vein used for vascular access for hemodialysis. The communication may be a direct fistula (AV fistula) (e.g. Brescia Cimino fistula), brachiocephalic fistula or an interposed conduit (AV graft) (e.g. brachiocephalic loop graft). The conduit may be an autogenous vessel or synthetic material. Percutaneous transluminal angioplasty (PTA): An invasive procedure which, when successful, enlarges a narrowed vascular lumen. Typically, a balloon-tipped catheter is introduced percutaneously into the narrowed vessel. The balloon is inflated at the site of vascular stenosis, stretching the vessel and opening the lumen to restore adequate flow through the vessel. The balloon is removed after angioplasty. Thrombolysis: Pharmacologic and/or mechanical dissolution of a thrombus or blood clot. Infusion: Continuous intravascular administration of a medication containing solution lasting longer than sixty (60) minutes. Bolus injections are not considered infusions, regardless of the time required to inject the solution. Dialysis Access: An arteriovenous dialysis access. Embolization/ligation of collateral branch veins: AV fistulae depend on a single outflow vein to carry the flow, so that this vein can enlarge to the point it is easily punctured and has brisk flow. If branch veins are large enough to siphon off a significant amount of flow, no single vein will enlarge enough to be used. Closing off the side branches may allow the outflow vein to mature. The side branches may be closed off surgically by tying off the branches, or may be closed off by placement of occlusive material into the side branch through a catheter (embolization). Indications: Evaluation of Dialysis Access Dysfunction - Clinical FindingsTypically, the clinical examination provides adequate information to determine whether there is hemodynamically significant dialysis shunt dysfunction. The following clinical findings are considered diagnostically specific and appropriate indications to initiate therapies to re-establish physiologically appropriate flow in the dialysis fistula.Venous outflow impediment clinical findings include: elevated venous pressure in the AV dialysis access; elevated venous/arterial ratio (static venous pressure ratio - above 40%); prolonged bleeding following needle removal; inefficient dialysis; recirculation percentage greater than 10-15%; development of pseudoaneurysm(s); swelling of the extremity, face or neck; development of large superficial collateral venous channels; loss of "machine-like" bruit, i.e., short sharp bruit; and/or abnormal physical findings, specifically pulsatile graft/fistula or loss of thrill. Arterial inflow impediment clinical findings include: low pressure in graft even when outflow is manually occluded; ischemic changes of the extremity (steal syndrome); and/or diminished intra-access flow. PTA induced rupture; graft salvage (e.g., PTA is unsuccessful due to elastic recoil, stenosis has recurred or less than 3 months); central veins stenosis or occlusion; and aneurysm or pseudoaneurysm is present. Summary of Evidence N/A Analysis of Evidence (Rationale for Determination) N/A