Background

Policy (Criteria)

IV Hydration is considered MEDICALLY NECESSARY when all of the following criteria is met:

1. For terminally ill patients, documentation indicating that the treatment is palliative and in lieu of hospitalization. 
2. For all other patients:
   1. Documentation supporting clinical and/or laboratory evidence of hypovolemia prior to initiation of IV hydration. Examples include:
      1. Clinical: reduced urine output, decrease in blood pressure, increase in heart rate, orthostatic vital sign changes, weight loss and change in mental status. 
      2. Laboratory:  increased urine specific gravity, abnormal serum osmolality or electrolytes and elevated BUN or creatinine.
   2. For prolonged use, documentation supporting that patient is responding to IV hydration and that the medical condition is unresolved, and the patient is unable to tolerate adequate oral or enteral hydration.

The use of long-term IV Hydration is NOT MEDICALLY NECESSARY and considered INVESTIGATIONAL for treatment of postural orthostatic tachycardia syndrome (POTS). There are no studies (randomized controlled trials (RCT's)) that show long-term IV fluids help with POTS.

References

1. Boris JR, Moak JP. Pediatric Postural Orthostatic Tachycardia Syndrome: Where We Stand. Pediatrics. 2022 Jul 1;150(1):e2021054945. doi: 10.1542/peds.  2021-054945  . PMID: 35773520.
2. Medow MS, Guber K, Chokshi S, Terilli C, Visintainer P, Stewart JM. The Benefits of Oral Rehydration on Orthostatic Intolerance in Children with Postural Tachycardia Syndrome. J Pediatr. 2019 Nov;214:96-102. doi: 10.1016/j.jpeds.2019.07.041. Epub 2019 Aug 9. PMID: 31405524; PMCID: PMC6815702.
3. Moak JP, Leong D, Fabian R, Freedenberg V, Jarosz E, Toney C, Hanumanthaiah S, Darbari A. Intravenous Hydration for Management of Medication-Resistant Orthostatic Intolerance in the Adolescent and Young Adult. Pediatr Cardiol. 2016 Feb;37(2):278-82. doi: 10.1007/s00246-015-1274-6. Epub 2015 Oct 7. PMID: 26446285.
4. Raj SR, Guzman JC, Harvey P, Richer L, Schondorf R, Seifer C, Thibodeau-Jarry N, Sheldon RS. Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance. Can J Cardiol. 2020 Mar;36(3):357-372. doi: 10.1016/j.cjca.2019.12.024. PMID: 32145864.
5. Ruzieh M, Baugh A, Dasa O, Parker RL, Perrault JT, Renno A, Karabin BL, Grubb B. Effects of intermittent intravenous saline infusions in patients with medication-refractory postural tachycardia syndrome. J Interv Card Electrophysiol. 2017 Apr;48(3):255-260. doi: 10.1007/s10840-017-0225-y. Epub 2017 Feb 9. PMID: 28185102.
6. Sheldon RS, Grubb BP 2nd, Olshansky B, Shen WK, Calkins H, Brignole M, Raj SR, Krahn AD, Morillo CA, Stewart JM, Sutton R, Sandroni P, Friday KJ, Hachul DT, Cohen MI, Lau DH, Mayuga KA, Moak JP, Sandhu RK, Kanjwal K. 2015 heart rhythm society expert consensus statement on the diagnosis and treatment of postural tachycardia syndrome, inappropriate sinus tachycardia, and vasovagal syncope. Heart Rhythm. 2015 Jun;12(6):e41-63. doi: 10.1016/j.hrthm.2015.03.029. Epub 2015 May 14. PMID: 25980576; PMCID: PMC5267948.
7. Stewart JM, Boris JR, Chelimsky G, Fischer PR, Fortunato JE, Grubb BP, Heyer GL, Jarjour IT, Medow MS, Numan MT, Pianosi PT, Singer W, Tarbell S, Chelimsky TC; Pediatric Writing Group of the American Autonomic Society. Pediatric Disorders of Orthostatic Intolerance. Pediatrics. 2018 Jan;141(1):e20171673. doi: 10.1542/peds.2017-1673. Epub 2017 Dec 8. PMID: 29222399; PMCID: PMC5744271.
8. Vernino S, Bourne KM, Stiles LE, Grubb BP, Fedorowski A, Stewart JM, Arnold AC, Pace LA, Axelsson J, Boris JR, Moak JP, Goodman BP, Chémali KR, Chung TH, Goldstein DS, Diedrich A, Miglis MG, Cortez MM, Miller AJ, Freeman R, Biaggioni I, Rowe PC, Sheldon RS, Shibao CA, Systrom DM, Cook GA, Doherty TA, Abdallah HI, Darbari A, Raj SR. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting - Part 1. Auton Neurosci. 2021
9. Nov;235:102828. doi: 10.1016/j.autneu.  2021.102828  . Epub 2021 Jun 5. PMID: 34144933; PMCID: PMC8455420.
10. “Infusion, Normal Saline Solution, Sterile (500 Ml=1 Unit) J7040 - HCPCS Codes - Codify by AAPC.” Aapc.com, 2025, www.aapc.com/codes/hcpcs-codes/J7040. Accessed 2 July 2025.

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2025 Forward