`A4721` Dialysat sol fld vol > 999cc

Dialysate solution, any concentration of dextrose, fluid volume greater than 999 cc but less than or equal to 1999 cc, for peritoneal dialysis

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 A4721

Physician Fee Schedule (CY 2026, RVU26D)

Status X: statutory exclusion, not paid under the PFS.

Payer policies and prior authorization for A4721

Payer coverage policies that name A4721

A4721 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 IN.

CO: $20.63 (health_first_colorado), effective Jul 1, 2026
TX: $0.00 (dmepos_tos_9_e_j_l_and_r, Medical Supplier (Dme), non-facility), effective Jun 1, 2002
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.

A4721 Dialysat sol fld vol > 999cc