Administrative Coverage Decision for Non-Network Hemodialysis Provider
This request should be APPROVED based on the BadgerCare policy framework, as hemodialysis for ESRD is a medically necessary service that requires HMO authorization for out-of-network providers, and the clinical need is clearly established.
Policy Framework Analysis
The BadgerCare Standard Topic 408 policy explicitly permits non-network providers to serve HMO enrollees in three specific circumstances. Your case falls under the second exception: when the HMO has authorized (in writing) an out-of-plan referral to a non-network provider.
Key Policy Requirements
- Written authorization from the HMO is required for non-network providers to deliver services that would otherwise be covered under the HMO contract.
- The policy does not prohibit non-network providers from delivering in-network services (like hemodialysis) - it simply requires HMO authorization.
- Non-network providers cannot serve enrollees as private-pay patients, reinforcing that services must go through proper authorization channels.
Clinical Necessity Established
This 30-year-old female with ESRD requiring maintenance hemodialysis has clear medical necessity for ongoing dialysis treatment:
- Hemodialysis is life-sustaining treatment for patients with ESRD, with 2-year survival rates of approximately 56% and 5-year survival rates of 18% in dialysis populations 1.
- The request for 84 visits over 6 months (approximately 3 times weekly) aligns with standard hemodialysis adequacy guidelines that recommend thrice-weekly treatments 2.
- KDOQI guidelines recommend a minimum delivered Kt/V of 1.2 per treatment for thrice-weekly hemodialysis to prevent uremic complications and optimize survival 2.
Authorization Process
The HMO must provide written authorization for this out-of-network provider to deliver the requested hemodialysis services. The clinical documentation supports:
- Established ESRD diagnosis requiring ongoing renal replacement therapy 3.
- Appropriate treatment frequency consistent with clinical practice guidelines for hemodialysis adequacy 2.
- MA certification of the provider ensures minimum quality standards are met.
Common Pitfall to Avoid
Do not deny this request based solely on non-network status. The policy framework allows for out-of-network services with proper HMO authorization. Denying medically necessary hemodialysis could result in life-threatening uremic complications, including hyperkalemia, volume overload, metabolic acidosis, and uremic encephalopathy 3, 4.
Recommendation
APPROVE the request with HMO written authorization for 84 hemodialysis visits at the specified facility. The provider's MA certification combined with the established medical necessity satisfies the requirements for out-of-network service authorization under BadgerCare Standard Topic 408.