HCPCS Level II › A codes A4680 Activated carbon filter, eaActivated carbon filter for hemodialysis, each
Medicare coverage: Special coverage instructions apply Status: active (October 2026 file) Medically Unlikely Edits (effective October 1, 2026) Practitioner: max 0 units per day (clinical), rationale: CMS Policy Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy DME supplier: max 0 units per day (clinical), rationale: CMS Policy Medicare pricing for A4680 Physician Fee Schedule (CY 2026, RVU26D) Status X: statutory exclusion, not paid under the PFS.
Payer policies and prior authorization for A4680 Payer coverage policies that name A4680 A4680 appears in 2 coverage policies from Aetna, Blue Cross & Blue Shield of Mississippi.
Payer Policy Role in policy Reviewed Document Aetna Dialysis (0541) covered if criteria are met Aug 26, 2026 payer document Blue Cross & Blue Shield of Mississippi Continuous Arteriovenous Hemofiltration (L.8.02.400) covered if criteria are met payer document
Medicaid fee-for-service Prior authorization required or conditional in CO, LA.
CO: $86.00 (chp_plus, non-facility), effective Jul 1, 2026 IN: $0.00 (professional, Advanced Practice Nurse (85%), non-facility), effective Apr 6, 2018 LA: $16.60 (dme), effective Sep 1, 2021 TX: $182.74 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Apr 1, 2017 VT: $0.00 (outpatient_hospital_opps), effective Feb 1, 2026 WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026 From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.