Hemodialysis for Schizophrenia

Number: 0291

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References


Policy

Scope of Policy

This Clinical Policy Bulletin addresses hemodialysis for schizophrenia. 

  1. Experimental, Investigational, or Unproven

    Hemodialysis for the treatment of schizophrenia is considered experimental, investigational, or unproven because the effectiveness of this approach has not been demonstrated and established.


Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code Code Description

CPT codes not covered for indications listed in the CPB:

90935 Hemodialysis procedure with single physician evaluation
90937 Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of dialysis prescription
90940 Hemodialysis access flow study to determine blood flow in grafts and arteriovenous fistulae by an indicator method

ICD-10 codes not covered for indications listed in the CPB:

F20.0 - F20.9 Schizophrenia
Z49.01 - Z49.32 Encounter for care involving renal dialysis
Z99.2 Dependence on renal dialysis

Background

A number of investigators presented reports of series of schizophrenic patients whose symptoms were reportedly improved with hemodialysis (American Psychiatric Association, 1979; Malek-Ahmdi et al, 1980).  Subsequent, well-designed, sham-controlled clinical trials, however, have found that hemodialysis had no significant effect on schizophrenia symptoms (Vanherweghern et al, 1979; Diaz-Buxo et al, 1980; Schulz and Van Kammen, 1981; Carpenter et al, 1983; Schulman et al, 1983; Vanherweghern et al, 1983; van Kammen et al, 1983; Wagemaker et al, 1983; Wagemaker et al, 1984; Schulman, 1985).

A Medicare National Coverage Determination states: "Scientific evidence supporting use of hemodialysis as a safe and effective means of treatment for schizophrenia is inconclusive at this time. Accordingly, Medicare does not cover hemodialysis for treatment of schizophrenia".

Cox and colleagues (2020) noted that increasing evidence suggested that circulating factors and immune dysfunction may contribute to the pathogenesis of schizophrenia.  In particular, pro-inflammatory cytokines, complement and autoantibodies against central nervous system (CNS) epitopes have recently been associated with psychosis.  Related concepts in previous decades led to several clinical trials of dialysis and plasmapheresis as treatments for schizophrenia.  These trials may have relevance for the current understanding of schizophrenia.  These researchers examined if dialysis or plasmapheresis are beneficial interventions in schizophrenia.  They carried out a systematic search in major electronic databases for high-quality studies (randomized, double-blinded trials with sham controls) applying either hemodialysis or plasmapheresis as an intervention in patients with schizophrenia, published in English from the start of records until September 2018.  These investigators found 9 studies meeting inclusion criteria, reporting on a total of 105 patients who received either sham or active intervention; 1 out of 8 studies reported a beneficial effect of hemodialysis on schizophrenia, 1 a detrimental effect and 6 no effect.  The 1 trial of plasmapheresis found it to be ineffective.  Adverse events (AEs) were reported in 23 % of patients.  Studies were at unclear or high risk of bias.  The authors concluded that it is unlikely that hemodialysis is a beneficial treatment in schizophrenia, although the studies were of small size and could not consider potential subgroups.  Plasmapheresis was only addressed by 1 study and warrants further exploration as a treatment modality in schizophrenia.


References

The above policy is based on the following references:

  1. Balow JE, Schulz SC, van Kammen DP, Bunney WE Jr. Controlled trial of hemodialysis in schizophrenia. Proceed Clin Dialysis Transplant Forum. 1980:10:203-206.
  2. Carpenter WT Jr, Sadler JH, Light PD, et al. Schizophrenia and dialysis. Artificial Organs. 1983;7(3):357-364.
  3. Carpenter WT Jr, Sadler JH, Light PD, et al. The therapeutic efficacy of hemodialysis in schizophrenia. N Engl J Med. 1983;308(12):669-675.
  4. Centers for Medicare & Medicaid Services (CMS). National coverage determination (NCD) for hemodialysis for treatment of schizophrenia (130.8). Baltimore, MD: CMS. undated.
  5. Cox ER, Marwick KFM, Hunter RW , et al. Dialysis and plasmapheresis for schizophrenia: A systematic review. Psychol Med. 2020;50(8):1233-1240.
  6. Diaz-Buxo JA, Caudle JA, Chandler JT, et al. Dialysis of schizophrenic patients: A double-blind study. Am J Psychiatry. 1980;137(10);1220-1222.
  7. Linkowski P, Vanherweghem JL, Jadot C, Mendlewicz J. Haemodialysis in schizophrenia. Lancet. 1979;2(8156-8157):1381-1382..
  8. Malek-Ahmadi P, Davis D, Sorkin MI, Callen KE. Effect of hemodialysis on hallucinations. Southern Med J. 1980;73(4):520-521.
  9. No authors listed. Schizophrenia and dialysis: Treatment or placebo. Conference Proceeding. 132nd Annual Meeting of the American Psychiatric Association. Chicago, IL, May 12-18, 1979. Arlington, VA: American Psychiatric Association; 1979.
  10. Schulman A. Hemodialysis in the treatment of a group of schizophrenic patients. Acta Psychiatr Scand Suppl. 1985;321:1-127.
  11. Schulz SC, Van Kammen DP. Dialysis in schizophrenia: A double-blind evaluation. Science. 1981;211(4486):1066-1068.
  12. Splendiani G, Giammaria U, Daniele M, Tancredi M. Dialysis in nonuremia. Contrib Nephrol. 1989;70:277-283.
  13. van Kammen DP, Schulz SC, Balow JE, et al. Failure of hemodialysis to diminish psychotic behavior in schizophrenia: Behavioral and psychophysiological evaluation. Artificial Organs. 1983;7(3):310-316.
  14. Vanherweghem JL, Linkowski P, Jadot C, Mendlewicz J. Haemodialysis in schizophrenia: A double blind study - preliminary report. Proceed Europ Dialysis Transplant Assoc. 1979;16:148-154.
  15. Vanherweghem JL, Linkowski P, Mendlewicz J. Hemodialysis in schizophrenics. A double-blind study. Arch Gen Psychiatry. 1983;40(2):211-214.
  16. Wagemaker H, Rogers JL, Cade R. Effectiveness of hemodialysis in chronic schizophrenic patients: A double-blind study. Artificial Organs. 1983;7(3):295-303.
  17. Wagemaker H, Rogers JL, Cade R. Schizophrenia, hemodialysis, and the placebo effect. Results and issues. Arch Gen Psychiatry. 1984;41(8):805-810.