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End Stage Renal Disease (ESRD)

Date: 07-26-2017

Overview

Hemodialysis and peritoneal dialysis are covered under EMA. The following treatments and associated services are approved in conjunction with the dialysis procedure.

  • • N18.6 – End Stage Renal Disease
  • • Z99.2 – Dependence on Renal Dialysis
  • Eligible providers

    Providers of dialysis services, including dialysis centers, hospitals and physicians may provide ESRD services.

    Eligible members

    People who have been approved for Emergency Medical Assistance are eligible for the services covered under ESRD when approved through an Emergency Medical Assistance Care Plan Certification Request.

    EMA Care Plan Certification (CPC) date spans
    EMA CPC requests for members with end stage renal disease are typically approved for 12 months.

    Covered services

    The following conditions are covered for patients with chronic ESRD.

  • • D63.1 - Chronic anemia due to decreased erythropoietin (a hormone produced by normal kidneys that controls red blood cell production
  • • N25.81 - Secondary Hyperparathyroidism which leads to increased calcium and phosphate levels in the blood that in turn cause renal osteodystrophy or bone mineralization deficiency
  • • I12.0 - Hypertension or high blood pressure which, if untreated can cause increased risk for heart disease and stroke 
  • MHCP covers the following standard treatments of these conditions:

  • • Administration of intravenous ( IV) erythropoietin( EPO)
  • • Administration of iron supplements (oral and intravenous) (Oral iron is of limited benefit for people receiving dialysis for ESRD because the absorption is limited. Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend oral therapy for chronic kidney disease patients who are not receiving dialysis.
  • • Treatment with phosphate binders
  • • Treatment with anti-hypertensives – angiotensin-converting enzyme (ACE) inhibitors (for example, captopril, lisinopril, enalapril); angiotensin receptor blockers (ARBs) (for example, valsartan, losartan); beta-blockers (for example, metoprolol, propranolol); calcium-channel blockers (for example, amlodipine, diltiazem, verapamil), alpha blocker and alpha 2 agonists (for example, clonidine); vasodilators (for example, minoxidil) classes of drugs.   
  • If the member is receiving dialysis for ESRD and currently has a diagnosis of a secondary condition that is caused by the ESRD and that presents a threat to the person’s health, bodily function or bodily organs, the additional diagnoses must be certified in conjunction with the ESRD diagnosis. Drugs administered by the dialysis facility are covered when billed on the dialysis claim. This includes intravenous iron supplements submitted on the dialysis claim. Approve the other drugs only for members with a current certified secondary diagnosis.

    MHCP covers IV iron that is prescribed as a home infusion therapy.

    Medications and guidelines

    The following outlines specific Emergency Medical Assistance Care Plan Certification (CPC) diagnosis requirements for the approval of specific drugs and drug categories for major program EH (emergency medical coverage for noncitizens ineligible for MA) members. Also listed are drugs that are never approved under the EH program.

    Specific Medications (including ICD-10 code when appropriate)

  • • Calcium Acetate – may be approved for the following diagnosis:
  • • N18.6 – End Stage Renal Disease
  • • Z99.2 – Dependence on Renal Dialysis
  • • Ibuprofen – only rarely approved when it is required to treat approved emergent or urgent CPC-approved diagnoses of pain or inflammatory conditions. It may also be approved in the following situations:
  • • When tapering off of opiates
  • • For a diagnosis of Lupus
  • • Opiates – approved only when they are required to treat an approved emergent or urgent CPC-approved diagnosis for significant pain, for example, cancer or fracture.
  • • Phoslo – may be approved for the following diagnosis:
  • • N18.6 – End Stage Renal Disease
  • • Z99.2 – Dependence on renal dialysis
  • • Renvela – may be approved for the following diagnosis:
  • • N18.6 – End Stage Renal Disease
  • • Z99.2 – Dependence on Renal Dialysis
  • • Tylenol – only rarely approved when it is required to treat an approved emergent or urgent CPC-approved diagnosis of pain.
  • • Velphoro – may be approved for the following diagnosis:
  • • N18.6 – End Stage Renal Disease
  • • Z99.2 – Dependence on Renal Dialysis
  • Categories of Drugs

  • • Antibiotics
  • Antibiotics can be approved only when they are required to treat an approved emergent or urgent CPC-approved diagnosis of infection.
  • • Anti-nausea drugs
  • Anti-nausea drugs may be approved for members receiving covered chemotherapy, for example, Zofran (ondansetron)
  • • Stool Softeners
  • Stool softeners can only rarely be approved when they are required to treat an approved emergent or urgent CPC-approved diagnosis of constipation. Stool softeners would not generally be the treatment of choice for an emergency constipation diagnosis. They are not approved to manage side effects of other medications.
  • Noncovered services

    Vitamins, including vitamin D are not covered under EMA. This includes vitamins that are marketed for renal deficiency like Dialyvite.

    Medications never approved under EMA
    The following are never approved under EMA:

  • • All vitamins, including prescription and nonprescription vitamins. Exception: IV iron is covered for renal dialysis patients when it is included on the renal dialysis claims.
  • • All acne and rosacea medications
  • • All contraceptive products
  • • All products used for smoking cessation
  • • All growth hormone products, including medications for precocious puberty
  • • All medications for Attention Deficit Hyperactivity Disorder (ADHD)
  • • All disulfiram (Antabuse), naltrexone (Vivitrol), buprenorphine (Suboxone, Subutex) products
  • • Buprenorphine and naloxone products for treatment of opioid dependency
  • • All aluminum chloride hexahydrate (Drysol) products
  • • All topically applied agents, except for topical anti-infectives
  • • All medications for hyperlipidemia
  • • All medications for urinary incontinence
  • • All steroids administered by the nasal route*
  • • All drugs not covered by Medical Assistance according to Minnesota Statutes.
  • Authorization Requirements

    Authorization process

    Authorization is required for all drugs approved with a CPC. Refer to the Authorization section for information about KEPRO, the medical review and CPC request agent.

  • • KEPRO determines if a drug is needed for treatment of the diagnosis for which the CPC was approved, but they cannot enter the drug authorizations. If a drug is requested that is not needed for treatment of the diagnosis for which the CPC was approved, KEPRO includes this information on the CPC approval letter.
  • • If a drug is requested for an approved EMA CPC diagnosis, KEPRO will notify Health Information Designs (HID) KEPRO sends this immediately because pharmacy claims are done in real time, point of sale, and drugs are not dispensed until claims are approved.
  • • HID processes the drug authorizations.
  • • KEPRO faxes Drug Prior Authorization Form (DHS-4424) (PDF) to HID with the required information.
  • • If additional clinical information is needed, HID requests that information from KEPRO. KEPRO receives the request for additional clinical information, compiles the requested information and faxes the requested information to HID. ID enters the approval or denial in the state system, which then generates notices to the provider and member. As a courtesy, HID notifies the pharmacy of the response.
  • Authorization criteria

  • • If an EMA recipient has a CPC approved for a diagnosis, authorization may still be required for a service.
  • • If a service requires authorization for Medical Assistance, it requires authorization for Emergency Medical Assistance.
  • • If the diagnosis on an authorization request has not been approved by the CPC process, the authorization request is denied.
  • Billing

    Follow all billing requirements under Billing in the Emergency Medical Assistance section.

    Legal references

    Minnesota Statutes 256B.06, Subdivision 4, (k), (1) (Eligibility: emergency medical conditions)
    Minnesota Statutes 256 B.0625, Subdivision 13
    (Covered Services: Drugs)

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