The adult failure to thrive (FTT) syndrome is characterized by unexplained
weight loss, malnutrition and disability. The syndrome has been associated
with multiple primary conditions (e.g., infections and malignancies), but
always includes 2 defining clinical elements, namely nutritional impairment
and disability. The nutritional impairment and disability associated with the
adult FTT syndrome may be severe enough to have an impact on the patient's
short-term survival.  
  
The adult FTT syndrome may manifest as an irreversible progression in the
patient's nutritional impairment/disability despite a trial of therapy (i.e.,
treatment intended to affect the primary condition responsible for the
patient's clinical presentation). The presence of comorbid conditions may
hasten the patient's clinical progression and as such should be identified and
addressed. This hospice policy addresses those cases where reversible causes
of severe nutritional impairment and disability (i.e., the adult FTT syndrome)
have been excluded.  
  
The Medicare hospice benefit is predicated upon physician-certification that
an individual entitled to Part A of Medicare is terminally ill. An individual
is considered to be terminally ill if the individual has a medical prognosis
that his or her life expectancy is 6 months or less if the terminal illness
runs its normal course. The medical criteria listed below would support a
terminal prognosis for individuals with the adult FTT syndrome. Medical
criteria 1 and 2 are important indicators of nutritional and functional status
respectively, and would thus, support a terminal prognosis if met.

1\. The nutritional impairment associated with the adult FTT syndrome should
be severe enough to impact a beneficiary's weight. It is expected that the
body mass index (BMI) of beneficiaries electing the Medicare hospice benefit
for the adult FTT syndrome will be below 22 kg/m2 and that the patient is
either declining enteral/parenteral nutritional support or has not responded
to such nutritional support, despite an adequate caloric intake.  
  
           BMI (kg/m 2)=703 x (weight in pounds) divided by (height in inches) 2  
  
2\. The disability associated with the adult FTT syndrome should be such that
the individual is significantly disabled. Significant disability would be
demonstrated by a Karnofsky or Palliative Performance Scale value less than or
equal to 40%.

Both the beneficiary's BMI and level of disability should be determined using
measurements/observations made within 6 months (180 days) of the most recent
certification/recertification date. If enteral nutritional support has been
instituted prior to the election of the Hospice Medicare Benefit and will be
continued, the BMI and level of disability should be determined using
measurements/observations made at the time of the initial certification and at
each subsequent recertification.  
  
At the time of recertification, recumbent measurement(s) (anthropometry) such
as mid-arm muscle area in cm 2 may be substituted for BMI with documentation
as to why a BMI could not be measured. This information will be subject to
review on a case-by-case basis.  
  
In the event a beneficiary presenting with a nutritional impairment and
disability does not meet the medical criteria listed above but is still
thought to be eligible for the Medicare Hospice Benefit, an alternate
diagnosis that best describes the clinical circumstances of the individual
beneficiary should be selected.