As a member of the Dialysis Vascular Access Coalition (DVAC), ASDIN has learned that several major payers and a number of minor insurance companies have adopted non coverage policies for percutaneous fistula creation (CPT codes 36836 for Ellipsys and 36837 for WavelinQ). In response to the recent ASDIN blog posts, here are copies of the Humana national non coverage policy and the Blue Cross Blue Shield of Texas non coverage policy along with a grid showing non coverage of pAVF creation or in cases where we have been successful in reversing decisions it is noted. All Blue Cross regions except Michigan, Massachusetts and their Highmark product in Pennsylvania, Delaware and West Virginia which will cover Ellipsys but not WavelinQ.

Here is a non coverage list as of August.  Please let us know if you have other payers who are not covering this procedure so we can add them to our list.

Medicare has coverage for pAVF creation through the new CPT Category 1 codes as noted above and we are not seeing Medicare coverage or payment issues.  Most Medicaid plans will cover pAVF but the amounts are usually less than $2,000. Medicare Advantage plans are allowed to create their own Medical Policies if there is no Medicare Local or National Coverage Decision (which there are none for pAVF creation).

Terry F. Litchfield, MPA, CPC
ASDIN Advocacy Chair