Ultrafiltration, Hemoperfusion and Hemofiltration — NCD 55 | CMS Coverage Update

TL;DR: The Centers for Medicare & Medicaid Services modified NCD 55, the National Coverage Determination governing Medicare coverage of ultrafiltration, hemoperfusion, and hemofiltration, effective January 9, 2026. Here's what billing teams need to do.

This update to the CMS ultrafiltration, hemoperfusion, and hemofiltration coverage policy clarifies which indications are covered, which are excluded, and where the documentation burden sits. NCD 55 in the Medicare system covers three distinct procedures with very different coverage rules — and billing teams that treat them as interchangeable will generate claim denials. The policy does not list specific CPT or HCPCS codes, which adds a layer of complexity your billing team needs to address proactively before January 9, 2026.

Quick-Reference Table

CMS Ultrafiltration, Hemoperfusion, and Hemofiltration Coverage Criteria and Medical Necessity Requirements 2026

NCD 55 covers three separate procedures under one policy. Each has its own medical necessity criteria. Treating them as a bundle is a billing mistake.

Ultrafiltration removes excess fluid from blood across a dialysis membrane using pressure. Medicare covers it — coverage has been in place since September 1, 1979. But predialysis ultrafiltration billing is where most facilities get tripped up.

CMS does not recognize an additional facility charge for predialysis ultrafiltration when it's performed alongside routine hemodialysis. The dialysis facility rate already accounts for the full range of complicated and uncomplicated nonacute treatments. Your facility cannot bill separately for predialysis ultrafiltration just because it requires additional staff time.

The exception is narrow: if a medical complication requires ultrafiltration to be performed separately from the dialysis treatment, an additional charge can be recognized. The claim must document specifically why the ultrafiltration could not have been performed at the same time as dialysis. Vague documentation will not hold up on audit.

Physician involvement under the coverage policy scales with patient stability. Unstable patients require the physician to be present at the initiation of dialysis and available in-house or in close proximity throughout. Stable patients with excessive weight gain require only modest additional physician involvement over routine outpatient hemodialysis. Your documentation needs to reflect which category each patient falls into.

Hemoperfusion removes substances from blood using a charcoal or resin artificial kidney. For life-threatening drug overdose, hemoperfusion is a covered service — whether or not the patient has renal failure. This is one of the few places in NCD 55 where coverage extends to patients without underlying kidney disease.

CMS expects physician presence at treatment initiation. The physician must remain in the hospital or an adjacent medical office for the entire procedure. Document that. CMS also expects that one or two treatments are typically sufficient to remove the toxic compound. If you bill for additional treatments, those claims require documented justification.

When hemoperfusion is performed concurrently with dialysis, reimbursement for hemoperfusion covers only the additional care rendered above and beyond the dialysis care. You cannot bill full hemoperfusion rates when dialysis is running simultaneously.

Hemofiltration removes fluid, electrolytes, and other low molecular weight substances. The NCD 55 policy summary for hemofiltration was truncated in the source document. Review the full NCD 55 text at CMS.gov for complete hemofiltration criteria before billing after January 9, 2026. If you're uncertain how the hemofiltration section applies to your patient mix, talk to your compliance officer before the effective date.

Whether ultrafiltration, hemoperfusion, or hemofiltration billing is at issue, the common thread is this: medical necessity must be documented at the procedure level, not just the diagnosis level. Each claim needs to show why the specific procedure was performed, under what clinical circumstances, and whether it was done concurrently with or separately from dialysis.

CMS Hemoperfusion Exclusions and Non-Covered Indications

This section is where the claims risk is highest. NCD 55 is explicit about what CMS will not cover.

Hemoperfusion to improve chronic hemodialysis results is not covered. The effects of using hemoperfusion for this purpose are unknown, and CMS does not consider it reasonable and necessary under §1862(a)(1) of the Act. If your team is billing hemoperfusion on dialysis patients without a covered indication — drug overdose or aluminum toxicity — those claims are non-covered by definition.

Hemoperfusion with deferoxamine (DFO) for iron overload is not covered. This applies to both symptomatic and asymptomatic patients with iron overload. CMS has not found sufficient evidence of efficacy in either population. This is a hard exclusion, not a documentation issue. No amount of additional clinical notes will make this a covered claim.

The one exception: hemoperfusion with DFO for aluminum toxicity is covered. CMS has determined this use is clinically efficacious. The distinction between iron overload and aluminum toxicity matters enormously here. Your documentation must clearly identify aluminum toxicity — not iron overload — as the indication when billing hemoperfusion with DFO. If you're seeing claims denied on this, the likely problem is imprecise diagnosis documentation.

This is also an area where prior authorization practices vary by Medicare Administrative Contractor. Check with your MAC to see whether prior authorization or prior auth review is required for hemoperfusion indications in your region, particularly for aluminum toxicity cases.

Coverage Indications at a Glance

CMS Ultrafiltration, Hemoperfusion, and Hemofiltration Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Ultrafiltration, Hemoperfusion, and Hemofiltration Under NCD 55

The policy data for NCD 55 does not list specific CPT, HCPCS Level II, or ICD-10-CM codes. This is a meaningful gap for ultrafiltration, hemoperfusion, and hemofiltration billing — and it means your team must do the mapping work internally.

Start by identifying which codes your facility currently uses for each of the three procedures. Then cross-reference those codes against the covered and non-covered indications in NCD 55. The covered/not-covered distinction in this policy is indication-driven, not code-driven — but that doesn't mean code selection is irrelevant. The wrong code on a covered indication still produces a claim denial.

Work with your billing consultant or MAC's provider outreach team to confirm the correct coding approach for each procedure type. This is particularly important for hemoperfusion with DFO, where the aluminum toxicity indication is covered and the iron overload indication is not. Your ICD-10-CM diagnosis code selection is the primary signal CMS will use to determine coverage. Get it right.