Proposed restrictions on payment for more frequent dialysis may be eased in the mid-West

Medicare administrative contractor Wisconsin Physicians Services, one of seven contractors that proposed payment restrictions more than a year ago for more frequent dialysis, released revised language last month retracting the restrictions.

Wisconsin Physicians Services (WPS), which covers states in the mid-West, has proposed to add the language, “Some patients due to chronic or long-term conditions may require dialysis that exceeds the usually covered 14 treatments per month” to its local coverage determination (LCD) rule regarding payment for dialysis sessions that are prescribed more than three times a week. The number of additional treatments and the reasoning behind the order would need to be present in the dialysis documentation, the contractor wrote.

The effective date, according to WPS, would be Feb. 16. However, the contractor must release the final regulation first and allow for a 45-day comment period before implementation.

At this point, only WPS is offering the revised language to allow more coverage for more frequent dialysis.

If the policy is published and implemented, it would be a major victory for home dialysis advocates, who protested when the seven MACs originally proposed language back in September 2017 that would restrict coverage of dialysis to three treatments per week. More frequent sessions would be covered only if the nephrologist and the care team could show that acute events were taking place that medically justified more treatments. Once the acute event was resolved, however, the MAC would terminate coverage for additional treatments. Without medical justification, that policy would eliminate coverage for patients who choose nocturnal dialysis at home more than three times a week or for those patients who wanted to do dialysis for a short period each day.

The MACs offered public hearings on the proposed rules in November and December 2017, where they received comments and testimony from more than 400 nephrologists and kidney care advocates against the more restrictive coverage.

“[The Renal Physicians Association] recognizes that a thrice-weekly dialysis regimen will be sufficient for many if not most dialysis patients, but there will still be a subpopulation who experience acute problems that occur on a chronic basis and we believe policy such as set forth in this LCD creates a restriction that is counter to the underlying purpose of the ESRD program,” wrote RPA president Mike Shapiro, MD. “ ... Coverage by the MACs is medically appropriate for conditions or events that are chronically occurring, in addition to those acute events that infrequently require an extra dialysis treatment.”

References:

www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55703&&&&&&&&&&ver=5&Cntrctr=268&ContrVer=1&CntrctrSelected=268*1&s=All&DocType=Active%7cFuture&bc=AAIAAAIAAAAA

www.healio.com/nephrology/kidney-care-community/news/online/%7b57b46456-0e9d-4a37-8bfa-74af328fb58b%7d/other-viewpoints

 

Medicare administrative contractor Wisconsin Physicians Services, one of seven contractors that proposed payment restrictions more than a year ago for more frequent dialysis, released revised language last month retracting the restrictions.

Wisconsin Physicians Services (WPS), which covers states in the mid-West, has proposed to add the language, “Some patients due to chronic or long-term conditions may require dialysis that exceeds the usually covered 14 treatments per month” to its local coverage determination (LCD) rule regarding payment for dialysis sessions that are prescribed more than three times a week. The number of additional treatments and the reasoning behind the order would need to be present in the dialysis documentation, the contractor wrote.

The effective date, according to WPS, would be Feb. 16. However, the contractor must release the final regulation first and allow for a 45-day comment period before implementation.

At this point, only WPS is offering the revised language to allow more coverage for more frequent dialysis.

If the policy is published and implemented, it would be a major victory for home dialysis advocates, who protested when the seven MACs originally proposed language back in September 2017 that would restrict coverage of dialysis to three treatments per week. More frequent sessions would be covered only if the nephrologist and the care team could show that acute events were taking place that medically justified more treatments. Once the acute event was resolved, however, the MAC would terminate coverage for additional treatments. Without medical justification, that policy would eliminate coverage for patients who choose nocturnal dialysis at home more than three times a week or for those patients who wanted to do dialysis for a short period each day.

The MACs offered public hearings on the proposed rules in November and December 2017, where they received comments and testimony from more than 400 nephrologists and kidney care advocates against the more restrictive coverage.

“[The Renal Physicians Association] recognizes that a thrice-weekly dialysis regimen will be sufficient for many if not most dialysis patients, but there will still be a subpopulation who experience acute problems that occur on a chronic basis and we believe policy such as set forth in this LCD creates a restriction that is counter to the underlying purpose of the ESRD program,” wrote RPA president Mike Shapiro, MD. “ ... Coverage by the MACs is medically appropriate for conditions or events that are chronically occurring, in addition to those acute events that infrequently require an extra dialysis treatment.”

References:

www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55703&&&&&&&&&&ver=5&Cntrctr=268&ContrVer=1&CntrctrSelected=268*1&s=All&DocType=Active%7cFuture&bc=AAIAAAIAAAAA

www.healio.com/nephrology/kidney-care-community/news/online/%7b57b46456-0e9d-4a37-8bfa-74af328fb58b%7d/other-viewpoints