Medicare coverage of hospice depends on a physician’s certification that an individual’s prognosis is a life expectancy of six months or less if the terminal illness runs its normal course.

A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific decline in clinical status guidelines.

Alternatively, the non-disease specific guidelines, plus the applicable disease-specific guidelines listed below can also establish the necessary expectancy.

PART 1: Decline in clinical status guidelines

  • Decline in clinical status guidelines

    These changes in clinical variables are listed in order of their likelihood to predict poor survival, the most predictive first and the least predictive last. No specific number of variables must be met, but fewer of those listed first (more predictive) and more of those listed last (least predictive) would be expected to predict longevity of six months or less.

     

    1. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results
      1. Clinical Status
        1. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract.
        2. Progressive inanition as documented by
          • • Weight loss not due to reversible causes such as depression or use of diuretics
          • • Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression or use of diuretics
          • • Decreasing serum albumen or cholesterol
        3. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption.
      2. Symptoms
        1. Dyspnea with increasing respiratory rate
        2. Cough, intractable
        3. Nausea/vomiting poorly responsive to treatment
        4. Diarrhea, intractable
        5. Pain requiring increasing doses of major analgesics more than briefly.
      3. Signs
        1. Decline in systolic blood pressure to below 90 or progressive postural hypotension
        2. Ascites
        3. Venous, arterial or lymphatic obstruction due to local progression or metastatic disease
        4. Edema
        5. Pleural / pericardial effusion
        6. Weakness
        7. Change in level of consciousness
      4. Laboratory
        1. Increasing pCO2 or decreasing pO2 or decreasing SaO2
        2. Increasing calcium, creatinine or liver function studies
        3. Increasing tumor markers (e.g. CEA, PSA)
        4. Progressively decreasing or increasing serum sodium or increasing serum potassium
    2. Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) from <70% due to progression of disease.
    3. Increasing emergency room visits, hospitalizations, or physician’s visits related to hospice primary diagnosis
    4. Progressive decline in Functional Assessment Staging (FAST) for dementia (from ≥7A on the FAST)
    5. Progression to dependence on assistance with additional activities of daily living
    6. Progressive stage 3-4 pressure ulcers in spite of optimal care

PART II: Non-disease specific baseline guidelines

  • Both guidelines should be met

    1. Physiologic impairment of functional status as demonstrated by declining Karnofsky Performance Status (KPS) Palliative Performance Score (PPS)
    2. Dependence on assistance for two or more activities of daily living (ADLs)
      • • Feeding
      • • Ambulation
      • • Continence
      • • Transfer
      • • Bathing
      • • Dressing

    Note: The word “should” in the disease specific guidelines means that on medical review the guideline so identified will be given great weight in making a coverage determination. It does not mean, however, that meeting the guideline is obligatory.

PART III: Co-morbidities

  • Co-morbidities

    Although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility.

     

    1. Chronic obstructive pulmonary disease
    2. Congestive heart failure
    3. Ischemic heart disease
    4. Diabetes mellitus
    5. Neurologic disease (CVA, ALS, MS, Parkinson’s)
    6. Renal failure
    7. Liver Disease
    8. Neoplasia
    9. Acquired immune deficiency syndrome
    10. Dementia

PART IV: Disease Specific Guidelines

  • Cancer

    1. Disease with distant metastases at presentation OR
    2. Progression from an earlier stage of disease to metastatic disease with either:
      • 1. a continued decline in spite of therapy
      • 2. patient declines further disease directed therapy

    Note: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.

  • Amyotrophic Lateral Sclerosis

    Patients tend to have a constant overall rate of decline, whether rapid or slow:

    1. Critically Impaired Breathing Capacity occurring over the past 12 months with all of the following:
      • a. Dyspnea at rest
      • b. Supplemental O2 at rest
      • c. No ventilator or ventilator only for comfort. A vital capacity < 30% is supportive, if available or
    2. Rapid Progression and Critical Nutritional Impairment with all of the following in the past 12 months:
      • a. Bed-bound
      • b. Barely or unintelligible speech
      • c. Pureed diet
      • d. Major assist in all ADLs
      • e. Insufficient oral intake
      • f. Continuing weight loss
      • g. Absence of artificial feeding methods, except to relieve hunger
    3. Rapid Progression and Life Threatening Complications with one of the following in the past 12 months:
      • a. Recurrent aspiration pneumonia
      • b. Upper UTI
      • c. Sepsis
      • d. Recurrent fever in spite of antibiotics
      • e. Stage 3/4 decubitus ulcers

  • Alzheimer’s disease and related disorders

    1. Dependent in 3/6 ADLs
    2. Urinary or fecal incontinence (intermittent or constant)
    3. FAST 7A- Unable to speak limited to approximately ≤ 6 intelligible different words in an average day or in the course of an intensive interview.
    4. One of the following in the past 12 Months:
      • a. Aspiration pneumonia
      • b. UTI
      • c. Septicemia
      • d. Stage 3/4 decubitus ulcers
      • e. Recurrent fever on antibiotics
      • f. Weight loss > 10% in past six months/ albumin < 3.0

    The FAST scale is used to determine the functional and mental status of a patient with Alzheimer’s. To be hospice appropriate, a patient with Alzheimer’s Disease or related disorders must have a FAST of 7A or greater. The presence of co-morbid conditions (Heart disease, Diabetes, COPD, CVA, etc.) will support eligibility.

    Functional Assessment Staging Scale (FAST)

    1. No difficulty either subjectively or objectively
    2. Complains of forgetting location of objects. Subjective work difficulties
    3. Decreased job functioning evident to co-workers. Difficulty in traveling to new locations, Decreased organizational capacity
    4. Decreased ability to perform complex tasks (planning dinner for guests, handling personal finances, forgetting to pay bills)
    5. Requires assistance in choosing proper clothing to wear for the day, season or occasion, (e.g. pt may wear the same clothing repeatedly)
    6. Occasionally or more frequently over the past few weeks:
      • a. Improperly putting on clothes without assistance or cueing
      • b. Unable to bathe properly (not able to choose proper water temp)
      • c. Inability to handle mechanics of toileting (e.g., forget to flush the toilet, does not wipe properly or properly dispose of toilet tissue)
      • d. Urinary incontinence
      • e. Fecal incontinence
      • a. Unable to speak limited to approximately ≤ 6 intelligible different words in an average day or in the course of an intensive interview.
      • b. Speech is limited to the use of a single intelligible word in an average day or in the course of an intensive interview
      • c. Ambulatory ability is lost (cannot walk without personal assistance or the use of assistive devices)
      • d. Cannot sit up without assistance (e.g., the individual will fall over if there are not lateral rests [arms] on the chair.)
      • e. Loss of ability to smile.
      • f. Loss of ability to hold up head independently

  • Stroke/Coma

    The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of stroke. Medical criteria 1 and 2 are important indicators of functional and nutritional status respectively, and would thus support a terminal prognosis if met.

    1. PPS equal to or less than 40%
    2. Inability to maintain hydration and caloric intake with one of the following:
      • a. Weight loss greater than 10% during the previous 6 months or 7.5% in the last 3 months
      • b. Serum albumin less than 2.5
      • c. Current history of pulmonary aspiration not responsive to speech therapy intervention
      • d. Dysphagia that prevents the patient from receiving adequate food and fluid necessary to sustain life in a patient who does not receive artificial nutrition or hydration
      • e. Sequential caloric counts documenting inadequate calorie and fluid intake

    Supportive documentation:

    • • Aspiration pneumonia
    • • UTIdfd
    • • Sepsis
    • • Decubitus ulcers stage 3-4
    • • Recurrent fever despite antibiotics

    The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology):

    Comatose patients with any three of the following on day three of coma:

    1.  Abnormal brain stem response
    2. Absent verbal response
    3. Absent withdrawal response to pain

  • Heart Disease

    The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Medical criteria 1 and 2 are important indications of the severity of heart disease and would thus support a terminal prognosis if met:

    1. Optimally treated with diuretics, vasodilators, ace inhibitors. If not explain why (hypotension or renal disease) OR Patient is either not a candidate for or declines surgical procedures AND
    2. Class IV of NYHA (Physical activity causes discomfort, symptoms are present at rest)

    Supportive documentation:

    • • Orthopnea
    • • Paroxysmal nocturnal dyspn
    • • Dependent pitting edema
    • • Syncope
    • • Weakness
    • • Chest pain
    • • Diaphoresis
    • • Cachexia
    • • Jugular vein distention
    • • Rales
    • • Liver Enlargement
    • • History of cardiac arrest or resuscitation
    • • Arrhythmias
    • • Brain embolism from cardiac origin (CVA)
    • • Significant congestive heart failure may be documented by an ejection fraction of ≤20%, but is not required if not available.

  • Pulmonary Disease

    Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of six months or less) if they meet the following criteria.

    1. Dyspnea at Rest and Minimal Exercise Tolerance (with FEV1 < 30% if available) AND
    2. Progression of Disease with Increased ER Visits, Hospitalizations or MD Home Visits (documented serial decrease in FEV1 40 ml/year if available) AND
    3. PO2 < 55 mm Hg ON ROOM AIR or O2 SAT < 88 ON O2 or Pco2 > 50 mm Hg

    Supportive documentation:

    • • Cor pulmonale
    • • Weight loss, 10% in past six months
    • • HR > 100/min at rest

  • Liver Disease

    Patients will be considered to be in the terminal stage of liver disease (life expectancy of six months or less) if they meet the following criteria:

    1. PT > 5 sec. over control or INR 1.5 and albumin < 2.5
    2. One of the following:
      • a. Refractory ascites or non-compliance
      • b. Spontaneous bacterial peritonitis
      • c. Hepato-renal syndrome
      • d. Refractory encephalopathy or non-compliance
      • e. Recurrent esophageal variceal bleeding despite treatment

    Supportive documentation:

    • • Weight loss > 10%
    • • Muscle wasting/loss of strength
    • • Continued alcohol consumption
    • • Hepatocellular cancer
    • • HBsAg positive
    • • Hepatitis C refractory to treatment

  • Renal Disease

    Patients will be considered to be in the terminal stage of renal disease (life expectancy of six months or less) if they meet the following criteria.

    Acute renal failure

    1. The patient is not seeking dialysis or renal transplant
    2. Creatinine clearance
    3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)

    Supportive documentation

    • • Mechanical ventilation
    • • Malignancy (other organ system)
    • • Chronic lung disease
    • • Advanced cardiac disease
    • • Advanced liver disease
    • • Sepsis
    • • Immunosuppression/AIDS
    • • Albumin
    • • Cachexia
    • • Platelet count <25,000
    • • Disseminated intravascular coagulation
    • • Gastrointestinal bleeding

    Chronic renal failure

    1. The patient is not seeking dialysis or renal transplant
    2. Creatinine clearance
    3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)

    Supportive documentation

    • • Uremia
    • • Oliguria (
    • • Intractable hyperkalemia (>7.0) not responsive to treatment
    • • Uremic pericarditis
    • • Hepatorenal syndrome
    • • Intractable fluid overload, not responsive to treatment

  • HIV Disease

    Patients will be considered to be in the terminal stage the illness (life expectancy of six months or less) if they meet the following criteria (1 and 2 must be present)

    1. Decreased performance status, as measured by the PPS scale, of greater than or equal to 50%
    2. Viral load > 100,000 copies/ml AND/OR
    3. CD4 < 25 cells/mm with functional status mainly sitting/lying plus progressive disease (HIV dementia, 10% weight loss in 6 months, opportunistic infections, HIV-related cancer)

    Supportive documentation

    • • Chronic persistent diarrhea for one year
    • • Persistent serum albumin <2.5
    • • Concomitant, active substance abuse
    • • Age >50 years
    • • Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy
    • • Advance AIDS dementia complex
    • • Toxoplasmosis
    • • Congestive heart failure

  • Other Terminal Illness

    Observable and documented deterioration in overall clinical condition in the past 6 months as evidenced by any of the following:

    1. Multiple physician assessments documenting deterioration
    2. Multiple hospital/ER visits
    3. Progressive decubitus ulcers
    4. Decline in functioning status with a PPS of less than 40%
    5. Systolic BP less than 90
    6. Progressive dependence of ADLs
    7. Persistent nausea and vomiting
    8. Recent impaired nutritional status
    9. Progressive weight loss
    10. Decreasing serum albumin—less than 3.0
    11. Malnutrition with declining BMI
    12. Requires oxygen at rest
    13. Declines artificial ventilation
    14. A combination of disease processes which, when reviewed together, present a picture of structural and functional impairment.