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Medical guidelines for determining appropriateness of hospice referral: Disease-specific guidelines

Medical guidelines for determining appropriateness of hospice referral: Disease-specific guidelines
A patient will be considered to have a life expectancy of 6 months and be eligible for hospice services if they meet criteria for the following disease-specific baseline guidelines as well as evidence of decline as outlined in non-disease-specific baseline guidelines (shown on a separate table):
Cancer diagnoses
Disease with metastases at presentation OR
Progression from an earlier stage of disease to metastatic disease with either continued decline in spite of therapy or patient declines further disease-directed therapy.
NOTE: Certain cancers with poor prognoses (eg, small-cell lung cancer, brain cancer, and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section
Dementia due to Alzheimer disease and related disorders
Patients will be considered to be in the terminal stage of dementia (life expectancy of 6 months or less) if they meet all of the following criteria:
  • Stage 7 or beyond according to the Functional Assessment Staging Scale; unable to walk, dress, and bathe without assistance; urinary and fecal incontinence (intermittent or constant); no consistently meaningful verbal communication (stereotypical phrases only or the ability to speak is limited to 6 or fewer intelligible words); AND
  • At least 1 medical complication within the past 12 months: aspiration pneumonia, pyelonephritis, septicemia, multiple stage 3 to 4 decubitus ulcers, recurrent fever after antibiotics, inability to maintain sufficient fluid and calorie intake (≥10% weight loss over previous 6 months or serum albumin <2.5 g/dL).
NOTE: This section is specific for Alzheimer disease and related disorders and is not appropriate for other types of dementia.
Heart disease
Patients will be considered to be in the terminal stage of heart disease (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 should be present; factors from 3 will add supporting documentation):
  1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease, or the patient is either not a candidate for surgical procedures or they decline those procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for not being on these drugs, eg, hypotension or kidney disease.)
  1. Patients with congestive heart failure or angina should meet the criteria for the New York Heart Association (NYHA) Class IV. (Class IV patients with heart disease have an inability to carry on any physical activity. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of ≤20%, but assessment of ejection fraction is not required if not already available.
  1. Documentation of the following factors supports but is not required to establish eligibility for hospice care: treatment-resistant symptomatic supraventricular or ventricular arrhythmias, history of cardiac arrest or resuscitation, history of unexplained syncope, brain embolism of cardiac origin, or concomitant HIV disease.
HIV disease
Patients will be considered to be in the terminal stage of their illness (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 should be present; factors from 3 will add supporting documentation):
  1. CD4 count <25 cells per microliter or persistent (2 or more assays at least 1 month apart) viral load >100,000 copies/mL, plus 1 of the following:
  • Central nervous system (CNS) lymphoma, untreated or persistent despite treatment; wasting (loss of at least 10% lean body mass); mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused; progressive multifocal leukoencephalopathy; systemic lymphoma, with advanced HIV disease and partial response to chemotherapy; visceral Kaposi sarcoma, unresponsive to therapy; kidney failure in the absence of dialysis; cryptosporidium infection; toxoplasmosis, unresponsive to therapy.
  1. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, ≤50%.
  1. Documentation of the following factors will support eligibility for hospice care: chronic persistent diarrhea for 1 year; persistent serum albumin <2.5 g/dL; concomitant, active substance abuse; age >50 years; absence of or resistance to effective antiretroviral, chemotherapeutic, and prophylactic drug therapy related specifically to HIV disease; advanced AIDS dementia complex; toxoplasmosis; congestive heart failure, symptomatic at rest; advanced liver disease.
Liver disease
Patients will be considered to be in the terminal stage of liver disease (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 should be present; factors from 3 will lend supporting documentation):
  1. Both prolonged prothrombin time (more than 5 seconds over control or INR >1.5) AND serum albumin <2.5 g/dL.
  1. End-stage liver disease with at least 1 of the following: ascites, refractory to treatment or patient noncompliant; spontaneous bacterial peritonitis; hepatorenal syndrome (elevated creatinine and BUN with oliguria [<400 mL/day] and urine sodium concentration <10 mEq/L); hepatic encephalopathy, refractory to treatment or patient noncompliant; recurrent variceal bleeding, despite intensive therapy.
  1. Documentation of the following factors will support eligibility for hospice care: progressive malnutrition; muscle wasting with reduced strength and endurance; continued active alcoholism (>80 g ethanol/day); hepatocellular carcinoma; chronic hepatitis B virus infection (HBsAg-positive); hepatitis C infection, refractory to interferon treatment.
Pulmonary disease
Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of 6 months or less) if they meet the following criteria. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end-stage pulmonary disease (1 and 2 should be present; documentation of 3, 4, and 5 will lend supporting documentation):
  1. Severe chronic lung disease as documented by both of the following:
  • Disabling dyspnea at rest, poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, eg, bed to chair existence, fatigue, and cough (documentation of forced expiratory volume in 1 second [FEV1], <30% predicted value after bronchodilator, is objective evidence for disabling dyspnea but is not necessary to obtain).
  • Progression of end-stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing clinician home visits prior to initial certification (documentation of serial decrease of FEV1 >40 mL/year is objective evidence for disease progression but is not necessary to obtain).
  1. Hypoxemia at rest on room air, as evidenced by pO2 ≤55 mmHg, or oxygen saturation ≤88%, determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records), OR hypercapnia, as evidenced by pCO2 ≥50 mmHg (this value may be obtained from recent [within 3 months] hospital records).
  1. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale, eg, not secondary to left heart disease or valvulopathy).
  1. Unintentional progressive weight loss >10% of body weight over the preceding 6 months.
  1. Resting tachycardia >100/minute.
Kidney disease (acute and chronic)
Patients will be considered to be in the terminal stage of kidney disease (life expectancy of 6 months or less) if they meet the following criteria:
Acute kidney failure (1 and either 2, 3, or 4 should be present; factors from 5 will lend supporting documentation):
  1. The patient is not seeking dialysis or kidney transplant or is discontinuing dialysis. As with any other condition, an individual with kidney disease is eligible for the hospice benefit if that individual has a prognosis of 6 months or less, if the illness runs its normal course. There is no regulation precluding patients on dialysis from electing hospice care. However, the continuation of dialysis will significantly alter a patient's prognosis and thus potentially impact that individual's eligibility.

    When an individual elects hospice care for end-stage kidney disease (ESKD) or for a condition to which the need for dialysis is related, the hospice agency is financially responsible for the dialysis. In such cases, there is no additional reimbursement beyond the per diem rate. The only situation in which a beneficiary may access both the hospice benefit and the ESKD benefit is when the need for dialysis is not related to the patient's terminal illness.
  1. Creatinine clearance <10 cc/minute (<15 cc/minute for diabetics), or <15 cc/minute (<20 cc/minute for diabetics) with comorbidity of congestive heart failure.
  1. Serum creatinine >8.0 mg/dL (>6.0 mg/dL for diabetics).
  1. Estimated glomerular filtration rate (GFR) <10 mL/minute.
  1. Comorbid conditions: mechanical ventilation, malignancy (other organ system), chronic lung disease, advanced cardiac disease, advanced liver disease, immunosuppression/AIDS, albumin <3.5 g/dL, platelet count <25,000/microL, disseminated intravascular coagulation, gastrointestinal bleeding.
Chronic kidney disease (1 and either 2 or 3 should be present; factors from 4 will lend supporting documentation):
  1. The patient is not seeking dialysis or kidney transplant or is discontinuing dialysis; as with any other condition, an individual with kidney disease is eligible for the hospice benefit if that individual has a prognosis of 6 months or less, if the illness runs its normal course. There is no regulation precluding patients on dialysis from electing hospice care. However, the continuation of dialysis will significantly alter a patient's prognosis and thus potentially impact that individual's eligibility.

    When an individual elects hospice care for ESKD or for a condition to which the need for dialysis is related, the hospice agency is financially responsible for the dialysis. In such cases, there is no additional reimbursement beyond the per diem rate. The only situation in which a beneficiary may access both the hospice benefit and the ESKD benefit is when the need for dialysis is not related to the patient's terminal illness.
  1. Creatinine clearance <10 cc/minute (<15 cc/minute for diabetics), or <15 cc/minute (<20 cc/minute for diabetics) with comorbidity of congestive heart failure.
  1. Serum creatinine >8.0 mg/dL (>6.0 mg/dL for diabetics).
  1. Signs and symptoms of kidney failure: uremia; oliguria (<400 cc/24 hours); intractable hyperkalemia (>7.0 mEq/L), not responsive to treatment; uremic pericarditis; hepatorenal syndrome; intractable fluid overload, not responsive to treatment.
Stroke or coma
Patients will be considered to be in the terminal stages of stroke or coma (life expectancy of 6 months or less) if they meet the following criteria:
Stroke:
  • KPS or Palliative Performance Scale of 40% or less.
  • Inability to maintain hydration and caloric intake with 1 of the following: weight loss >10% in the last 6 months or >7.5% in the last 3 months; serum albumin <2.5 g/dL; current history of pulmonary aspiration, not responsive to speech-language pathology intervention; sequential calorie counts documenting inadequate caloric/fluid intake; dysphagia severe enough to prevent the patient from continuing food and fluids necessary to sustain life, in a patient who does not receive artificial nutrition and hydration.
Coma (any etiology): Comatose patients with any 3 of the following on day 3 of the coma: abnormal brain stem response, absent verbal response, absent withdrawal response to pain, serum creatinine >1.5 mg/dL.
Documentation of the following factors will support eligibility for hospice care:
  • Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, that support a terminal prognosis:
    • Aspiration pneumonia, upper urinary tract infection (pyelonephritis), refractory stage 3 to 4 decubitus ulcers, fever recurrent after antibiotics.
  • For stroke patients, documentation of diagnostic imaging factors that support poor prognosis after stroke include:
    • For non-traumatic hemorrhagic stroke: large-volume hemorrhage on CT (≥20 mL if intratentorial, ≥50 mL if supratentorial), ventricular extension of hemorrhage, surface area of involvement of hemorrhage ≥30% of cerebrum, midline shift ≥1.5 cm, obstructive hydrocephalus in a patient who declines or is not a candidate for ventriculoperitoneal shunt. For thrombotic/embolic stroke: large anterior infarcts with both cortical/subcortical involvement, large bihemispheric infarcts, basilar artery occlusion, bilateral vertebral artery occlusion.
Amyotrophic lateral sclerosis (ALS)
Patients are considered eligible for hospice care if they do not elect tracheostomy and invasive ventilation and display evidence of critically impaired respiratory function (with or without use of noninvasive positive pressure ventilation [NIPPV]) and/or severe nutritional insufficiency (with or without use of a gastrostomy tube).
Critically impaired respiratory function is as defined by:
  • Forced vital capacity (FVC) <40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs: dyspnea at rest, orthopnea, use of accessory respiratory musculature, paradoxical abdominal motion, respiratory rate >20/minute, reduced speech/vocal volume, weakened cough, symptoms of sleep-disordered breathing, frequent awakening, daytime somnolence/excessive daytime sleepiness, unexplained headaches, unexplained confusion, unexplained anxiety, unexplained nausea.
  • If unable to perform the FVC test, patients meet this criterion if they manifest 3 or more of the above symptoms/signs.
  • Severe nutritional insufficiency is defined as dysphagia with progressive weight loss of at least 5% of body weight with or without election for gastrostomy tube insertion.
  • These revised criteria rely less on the measured FVC and, as such, reflect the reality that not all patients with ALS can or will undertake regular pulmonary function tests.
KPS = 50: Requires considerable assistance and frequent medical care.
KPS <50: Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly.
HIV: human immunodeficiency virus; CD4: cluster of differentiation 4; AIDS: acquired immunodeficiency syndrome; INR: international normalized ratio; BUN: blood urea nitrogen; HBsAg: hepatitis B surface antigen; pO2: partial pressure of oxygen; pCO2: partial pressure of carbon dioxide; CT: computed tomography.
Sources:
  1. The NHO medical guidelines for non-cancer disease and local medical review policy: hospice access for patients with diseases other than cancer. Hosp J 1999.
  2. Centers for Medicare & Medicaid Services. Medicare Coverage Database. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=34538 (Accessed on January 5, 2021).
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