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MEDICARE HOSPICE CRITERIA

Condensed for quick reference; final decisions require physician judgment and full LCDs.

Need Part I OR (Part II + Part III)


PART II ........ Need A+B; C supports

  1. KPS or PPS < 70% ( <50% HIV; <40% stroke)
  2. Dependence on >1 ADL (bath, feed, dress, transfer, ambulate, continence)
  3. Comorbidities such as COPD, CHF, CAD, DM, Stroke, ALS, MS, Parkinson’s, CKD, Liver, Cancer, AIDS, Dementia, Immune or Autoimmune, RA, SLE
PART III ....... Disease specific criteria
Cancer: Poor prog (small cell, pancreatic, brain) or Mets + decline despite tx or declines tx

Alzheimer’s Dementias:
  1. FAST 7 = <7 words/visit + no consistent meaning to speech
  2. Needs assistance for all ADL’s (see Part II)
  3. In the last year, one of: aspiration pneumonia, pyelonephritis, sepsis, stage 3-4 ulcer, fever post antibiotic, albumin < 2.5, wgt ↓ >10%
Heart Disease: 1 + 2; 3 supports
  1. Optimally treated or declines treatment
  2. NYHA Class IV (mostly bedbound, symptoms at rest) or EF < 20% in CHF
  3. SVT/arrhythmias, hx resuscitation/arrest, hx unexplained syncope, cardiogenic stroke, HIV
Liver: 1 + 2; 3 supports
  1. INR > 1.5 AND albumin < 2.5
  2. One of: ascites, spontaneous bacterial peritonitis, hepatorenal syn, refractory encephalopathy, recurrent variceal bleeding despite therapy
  3. Malnutrition, muscle wasting, alcoholism (> 80g/d), hepatocellular Ca, Hep Bs Ag+, refractory Hep C
Pulmonary: 1 + 2; 3 supports
  1. a. Disabling SOB (fatigue, cough, bed to chair) or document FEV1 < 30% post tx and
    b. Increasing medical visits or declining FEV1 > 40 ml/yr
  2. pO2 < 56 mm or sat <89% OR pCO2 > 49 mm
  3. R CHF, wgt ↓ > 10% over 6 months, resting tachycardia > 100
Renal: 1 + 2; 3 supports
  1. Dialysis stopped or needed and chosen against
  2. One of : CrCl < 10 cc/min (< 15 CHF/;< 20 DM) OR Cr > 8.0 mg/dl (> 6.0 DM) OR in ARF: eGFR < 10 cc/min; OR in CKD: s/s of uremia: u/o < 400 cc/24 hr, K>7.0 w/ tx, uremic pericarditis, hepatorenal syn, fluid overload
  3. In ARF: comorbid vent, cancer, advanced lung/ CV / liver dz, AIDS, albumin < 3.5, Plt < 25, DIC, GI bleed; OR In CKD: eGFR <10 cc/min
Stroke: 1 + 2 + 3
  1. KPS/PPS < 40%
  2. Cannot maintain adequate Intake
  3. One of : wgt ↓ >10% in 6 months or 7.5% in 3 months; albumin < 2.5, aspiration despite evaluation, calorie counts w/ inadequate intake, dysphagia w/o artificial hydration/nutrition
Coma: 1; 2 - 4 supports
  1. On day 3: three of: abn brainstem response, absent verbal, absent withdrawal to pain, Cr > 1.5
  2. In last year: aspiration pneumonia, pyelonephritis, Stage 3-4 ulcers, fever post antibiotics
  3. CT findings: Hemorrhagic: ventricular blood, > 20 cc infratentorial or > 50 cc supratentorial, > 30% surface area, midline shift > 1.5 cm, obstructive hydrocephalus not treated by shunt
  4. Thrombotic: large anterior with cortical and subcortical involvement; bihemispheric stroke; basilar or bilateral vertebral artery
ALS: 1 + (2 or 3) + 4 and/or 5 supports
  1. Trajectory consistent with 6 months prognosis with muscle denervation widespread, no assisted ventilation
  2. Impaired breathing + FVC < 40% predicted + 2 out of: SOB rest, orthopnea, accessory muscle use, abdominal breathing, RR > 20, reduced speech due to breathing, weak cough, sleep disordered breathing, PND or awakening due to breathing, somnolence, unexplained headaches, confusion, anxiety, nausea
  3. 3 of the above symptoms (if cannot get FVC)
  4. Impaired swallowing with dysphagia AND at least 5% wgt loss
  5. Neurology opinion within 3 months of hospice admission
HIV/AIDS: 1 + 2; 3 supports
  1. CD4 < 25 cells/ ml or viral load persists > 100,000/ml + 1 of: CNS lymphoma, > 10% wgt ↓, cryptosporidium, progressive multifocal leukoencephalopathy, systemic lymphoma, visceral Kaposi’s, renal failure, toxoplasmosis or MAC despite tx or refuses tx
  2. KPS/PPS < 50%
  3. Chronic diarrhea, albumin < 2.5, substance abuse, age > 50, refuses or resistance to HIV tx, AIDS, CHF, liver failure, toxoplasmosis despite tx