Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-51 - HOSPICE CARE › Section 560-X-51-.04 - Recipient Eligibility

Current through Register Vol. 42, No. 9, June 28, 2024
In order to be eligible to elect hospice care under Medicaid,
				an individual must be:
(1) Medicaid
			 eligible for full benefits.
(2)
			 Certified by a physician as terminally ill and require hospice services which
			 are medically necessary for the palliation or are medically necessary for
			 symptom and pain management related to the terminal illness. Certification of
			 terminal illness must include specific clinical findings and other medical
			 documentation including, but not limited to, medical records, lab x-rays,
			 pathology reports, etc.
The hospice has the responsibility to establish and maintain a
				permanent medical record for each patient that includes the following:
(a) Physician certifications
(b) Services provided
(c) Recipient election statement(s)
(d) Interdisciplinary treatment plan of care
			 and updates
(e) Advance directive
			 documentation The documentation contained in the medical record must be a
			 chronological, complete record of the care provided to the hospice recipient.
			 The medical record must contain the Medicaid Hospice Election and Physician's
			 Certification, Form 165 that is signed and dated by the physician. A Form 165
			 must be present for each election period. Form 165, which was signed by the
			 recipient at the time of certification, may be signed by the physician for
			 recertification for each election period. The documentation must contain the
			 physicians' orders that include medication(s) taken by the recipient, an
			 assessment and a plan of care developed prior to providing care by the
			 attending physician, the medical director or physician designee, and the
			 interdisciplinary team. Identification of a specific terminal illness must be
			 documented and substantiated by labs, x-rays and other medical documentation
			 supporting the terminal illness as set forth by the Medicaid guidelines.
Failure to establish the hospice medical record as defined
				above shall result in a denial.
The hospice must retain medical records for at least three
				years after the current year.
Recipients residing in nursing facilities that elect the
				hospice benefit, but are subsequently determined to be ineligible for hospice
				care by Medicare or Medicaid, are not automatically approved for Medicaid
				reimbursement for nursing facility care if hospice payments are denied or
				recouped. Election of hospice care forfeits other Medicaid benefits.
Recipients who are denied hospice benefits in the nursing
				facility who intend to remain in the facility must apply and meet the nursing
				facility level of care criteria and the financial criteria for nursing home
				coverage by Medicaid.
After the initial certification has been approved, if the
				diagnosis changes, the recipient will be required to meet the initial criteria
				for the new diagnosis at the time of the six month recertification.
A person who reaches a point of stability and
				is no longer considered terminally ill must not be recertified for hospice
				services. The individual must be discharged to traditional Medicaid
				benefits.
Individuals seeking aggressive treatment shall
				not be certified for hospice services. "Aggressive treatment" means treatment
				that is intended to be life-prolonging or curative (rather than palliative) and
				would prevent the natural course of the terminal illness upon which they are
				seeking hospice services. Medicaid eligibility for the Hospice program, for
				recipients who are not dually eligible for Medicare, is based upon financial
				and medical criteria. The following medical criteria must be present for the
				terminal illnesses listed below. For diagnoses not found in the Alabama
				Medicaid Agency administrative code, for cases with evidence of other
				co-morbidities and the evidence of rapid decline, and for pediatric cases
				medical necessity review will be conducted on a case-by-case basis.
(a)
Hospice Criteria for
			 Adult Failure to Thrive Syndrome
1.
			 Terminal Illness Description: The adult failure to thrive 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 two defining clinical elements, namely
			 nutritional impairment and disability. The nutritional impairment and
			 disability associated with the adult failure to thrive syndrome must be severe
			 enough to impact the patient's short-term survival. The adult failure to thrive
			 syndrome presents as an irreversible progression in the patient's nutritional
			 impairment/disability despite therapy (i.e., treatment intended to affect the
			 primary condition responsible for the patient's clinical
			 presentation).
2. Criteria for
			 initial certification or recertification: Criteria below must be present at the
			 time of
initial certification or re-certification
for hospice. An
			 individual is considered to be terminally ill if the individual has a medical
			 prognosis that his or her life expectancy is six months or less if the terminal
			 illness runs its normal course. Patients must meet
(i) and (ii)
below:
(i) The nutritional impairment
			 associated with the adult failure to thrive syndrome must be severe enough to
			 impact a beneficiary's weight. The Body Mass Index (BMI) of beneficiaries
			 electing the Medicaid Hospice Benefit for the adult failure to thrive syndrome
			 must be below 22 kg/m 2 and the patient must be
			 either declining enteral/parenteral nutritional support or has not responded to
			 such nutritional support.
(ii) The
			 disability associated with the adult failure to thrive syndrome should be such
			 that the individual is significantly disabled. Significant disability must be
			 demonstrated by a Karnofsky or Palliative Performance Scale value less than or
			 equal to 40%.
Both the recipient's BMI and level of disability should be
				determined using measurements/observations made within six months (180 days) of
				the most recent certification/recertification date. If enteral nutritional
				support has been instituted prior to the hospice election 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 circumference in cm 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.
3. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits.
(b)
Hospice Criteria for Adult HIV
			 Disease
1. Terminal Illness
			 Description: An individual is considered to be terminally ill if the medical
			 prognosis indicates a life expectancy of six months or less.
2. Criteria for initial certification:
			 Criteria below must be present at the time of
initial
			 certification
for hospice. Patients will be considered to be in the
			 terminal stage of their illness (life expectancy of six months or less) if they
			 meet the following criteria:
HIV Disease
(
i) and (ii)
must be
				present; factors from (iii) will add supporting documentation)
(i) CD4+ Count less than 25 cells/mcL or
			 persistent viral load greater than 100,000 copies/ml, plus
one
of the following:
(I) CNS lymphoma
(II) Untreated, or not responsive to
			 treatment, wasting (loss of 33% lean body mass)
(III) Mycobacterium avium complex (MAC)
			 bacteremia, untreated, unresponsive to treatment, or treatment
			 refused
(IV) Progressive multifocal
			 leukoencephalopathy
(V) Systemic
			 lymphoma, with advanced HIV disease and partial response to
			 chemotherapy
(VI) Visceral Kaposi's
			 sarcoma unresponsive to therapy
(VII) Renal failure in the absence of
			 dialysis
(VIII) Cryptosporidium
			 infection
(IX) Toxoplasmosis,
			 unresponsive to therapy
(ii) Decreased performance status, as
			 measured by the Karnofsky Performance Status (KPS) scale, of less than or equal
			 to 50
(iii) Documentation of the
			 following factors will support eligibility for hospice care:
(I) Chronic persistent diarrhea for one
			 year
(II) Persistent serum albumin
			 less than 2.5 gm/dl
(III) Age
			 greater than 50 years
(IV) Absence
			 of antiretroviral, chemotherapeutic and prophylactic drug therapy related
			 specifically to HIV disease
(V)
			 Advanced AIDS dementia complex
(VI)
			 Toxoplasmosis
(VII) Congestive
			 heart failure, symptomatic at rest, New York Heart Association (NYHA)
			 classification Stage IV
3. Criteria for recertification: Criteria
			 below must be present at the time of
recertification
for hospice.
			 Both (i) and (ii) must be met. Patients will be considered to be in the
			 terminal stage of their illness (life expectancy of six months or less) if they
			 meet one of the conditions in (i) and meet the requirement in (ii):
(i) Persistent viral load greater than
			 100,000 copies/ml, plus
one
of the following:
(I) CNS lymphoma
(II) Untreated, or not responsive to
			 treatment, wasting (loss of 33% lean body mass)
(III) Mycobacterium avium complex (MAC)
			 bacteremia, untreated, unresponsive to treatment, or treatment
			 refused
(IV) Progressive multifocal
			 leukoencephalopathy
(V) Systemic
			 lymphoma, unresponsive or partially responsive to chemotherapy
(VI) Visceral Kaposi's sarcoma unresponsive
			 to therapy
(VII) Renal failure in
			 the absence of dialysis
(VIII)
			 Cryptosporidium infection
(IX)
			 Toxoplasmosis, unresponsive to therapy
(ii) Decreased performance status, as
			 measured by the Karnofsky Performance Status (KPS) scale, of less than or equal
			 to 50
(iii) Documentation of the
			 following factors will support eligibility for hospice care:
(I) Chronic persistent diarrhea for one
			 year
(II) Persistent serum albumin
			 less than 2.5 gm/dl
(III) Age
			 greater than 50 years
(IV) Absence
			 of antiretroviral, chemotherapeutic and prophylactic drug therapy related
			 specifically to HIV disease
(V)
			 Advanced AIDS dementia complex
(VI)
			 Toxoplasmosis
(VII) Congestive
			 heart failure, symptomatic at rest, New York Heart Association (NYHA)
			 classification Stage IV
4. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy
(ii)
			 Absence of supporting documentation of progression or rapid decline
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient on
			 antiretroviral, chemotherapeutic and prophylactic drug therapy related
			 specifically to HIV disease.
(v)
			 Patient is not eligible for full Medicaid benefits.
(c)
Hospice
			 Criteria for Adult Pulmonary Disease
1.
			 Terminal Illness Description: An individual is considered to be terminally ill
			 if the medical prognosis indicates a life expectancy of six months or
			 less.
2. Criteria for initial
			 certification: Criteria below must be present at the time of
initial
			 certification
for hospice. 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. The criteria refer to patients with various
			 forms of advanced pulmonary disease who eventually follow a final common
			 pathway for end stage pulmonary disease: (
i) and (ii)
must be
			 present; documentation of (iii), (iv) and/or (v) will lend supporting
			 documentation:
(i) Severe chronic lung
			 disease as documented by both factors below:
(I) Patient with Forced Expiratory Volume in
			 one second [FEV1], after bronchodilator, less than 30% of predicted and
			 disabling dyspnea at rest, poorly responsive to bronchodilators, resulting in
			 decreased functional capacity, e.g., bed to chair existence, fatigue, and cough
			 (documentation of Forced Expiratory Volume in one second [FEV1], after
			 bronchodilator, less than 30% of predicted is objective evidence for disabling
			 dyspnea and must be provided when performed). If the FEV1 has not been
			 performed, the clinical condition must support an FEV1 less than 30% of
			 predicted.
(II) Progression of end
			 stage pulmonary disease as documented by two or more episodes of pneumonia or
			 respiratory failure requiring ventilatory support within the last six months.
			 Alternatively, medical record documentation of serial decrease in FEV1 greater
			 than 40 ml/year for the past two years can be used to demonstrate
			 progression.
(ii)
			 Hypoxemia at rest on room air, with a current ABG PO2 at or below 59 mm Hg or
			 oxygen saturation at or below 89% taken at rest or hypercapnia, as evidenced by
			 PCO2 greater than or equal to 50 mmHg (these values may be obtained from recent
			 hospital records).
(iii) Cor
			 pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g.
			 not secondary to left heard disease or valvulopathy).
(iv) Unintentional progressive weight loss of
			 greater than 10% of body weight over the preceding six months.
(v) Resting tachycardia greater than
			 100/min.
3. Criteria for
			 recertification: Criteria below must be present at the time of
recertification
for hospice. Patients will be considered to be in
			 the terminal stage of their illness (life expectancy of six months or less) if
			 they meet (i) and (ii) below:
(i) Severe
			 disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting
			 in decreased functional capacity, e.g., bed to chair existence, fatigue, and
			 cough.
(ii) Hypoxemia at rest on
			 room air, with a current ABG PO2 at or below 59 mm Hg or oxygen saturation at
			 or below 89% taken at rest or hypercapnia as evidenced by PCO2 greater than or
			 equal to 50 mm Hg.
4.
			 Reasons for Denial
(i) Patients not meeting
			 the specific medical criteria in this policy.
(ii) Absence of supporting documentation of
			 progression or rapid decline.
(iii)
			 Failure to document terminal status of six months or less.
(iv) Patient is on non-emergent, artificial
			 ventilator support,
(v) Patient is
			 not eligible for full Medicaid benefits.
(d)
Hospice Criteria for Adult
			 Alzheimer's Disease &Related Disorders
1. Terminal Illness Description: An
			 individual is considered to be terminally ill if the medical prognosis
			 indicates a life expectancy of six months or less. Alzheimer's disease and
			 related disorders are further substantiated with medical documentation of a
			 progressive decline in the Reisburg Functional Assessment Staging (FAST) Scale,
			 within a six-month period of time, prior to the Medicaid hospice
			 election.
2. Criteria below must be
			 present at the time of
initial certification
and recertification
			 for hospice. Alzheimer's disease and related disorders may support a prognosis
			 of six months or less under many clinical scenarios. The structural and
			 functional impairments associated with a primary diagnosis of Alzheimer's
			 disease are often complicated by co morbid and/or secondary conditions.
			 Co-morbid conditions affecting beneficiaries with Alzheimer's disease are by
			 definition distinct from the Alzheimer's disease itself-examples include
			 coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD).
			 Secondary conditions on the other hand are directly related to a primary
			 condition - in the case of Alzheimer's disease examples include delirium and
			 pressure ulcers. The Reisberg Functional Assessment Staging (FAST) Scale has
			 been used for many years to describe Medicare beneficiaries with Alzheimer's
			 disease and a prognosis of six months or less. The FAST Scale is a 16-item
			 scale designed to parallel the progressive activity limitations associated with
			 Alzheimer's disease. Stage 7 identifies the threshold of activity limitation
			 that would support a six-month prognosis; however at least 4 of the 6-substage
			 FAST scale indicators must be present. The FAST Scale does not address the
			 impact of co-morbid or secondary conditions. The presence of secondary
			 conditions is thus considered separately by this policy. Patients must beet (i)
			 and (ii) below:
(i) To be eligible for
			 hospice, the individual must have documentation of a FAST scale level equal to
			 7 and documentation of at least 4 or 6 substage FAST scale indicators under
			 level 7.
FAST Scale Items:
Stage #1: No difficulty, either subjectively or objectively
				Stage #2: Complains of forgetting location of objects; subjective work
				difficulties Stage #3: Decreased job functioning evident to coworkers;
				difficulty in traveling to new locations Stage #4: Decreased ability to perform
				complex tasks (e.g., planning dinner for guests; handling finances)
Stage #5: Requires assistance in choosing proper clothing Stage
				#6: Decreased ability to dress, bathe, and toilet independently:
Sub-stage 6a: Difficulty putting clothing on properly Sub-stage
				6b: Unable to bathe properly; may develop fear of bathing Sub-stage 6c:
				Inability to handle mechanics of toileting (e.g., forgets to flush the toilet,
				does not wipe properly)
Sub-stage 6d: Urinary incontinence Sub-stage 6e: Fecal
				incontinence Stage #7: Loss of speech, locomotion, and consciousness:
Sub-stage 7a: Ability to speak limited to approximately a half
				dozen intelligible different words or fewer, in the course of an average day or
				in the course of an intensive interview Sub-stage 7b: All intelligible
				vocabulary lost (Speech ability limited to the use of a single intelligible
				word in an average day or in the course of an intensive interview - the person
				may repeat the word over and over)
Sub-stage 7c: Non-ambulatory (Ambulatory ability lost - cannot
				walk without personal assistance)
Sub-stage 7d: Unable to sit up independently (Cannot sit up
				without assistance - e.g., the individual will fall over if there are not
				lateral rests [arms] on the chair)
Sub-stage 7e: Loss of ability to smile Sub-stage 7f: Loss of
				ability to hold head up independently
(ii) Documentation of specific secondary
			 condition(s) related to Alzheimer's Disease must be present, including but not
			 limited to, Contractures, Pressure Ulcers, recurrent UTI, Dysphagia, Aspiration
			 Pneumonia.
3. Reasons
			 for Denial
(i) Patients not meeting the
			 specific medical criteria in this policy.
(ii) Absence of supporting documentation of
			 progression or rapid decline.
(iii)
			 Failure to document terminal status of six months or less.
(iv) Patient is not eligible for full
			 Medicaid benefits.
(e)
Hospice Criteria for Adult Stroke
			 and/or Coma
1. Terminal Illness
			 Description: An individual is considered to be terminally ill if the medical
			 prognosis indicates a life expectancy of six months or less.
2. Criteria below must be present at the time
			 of
initial certification
and recertification for hospice. The
			 medical criteria listed below would support a terminal prognosis for
			 individuals with a diagnosis of stroke. Patients must meet
(i) and (ii)
			 below:
(i) A Palliative Performance
			 Scale (PPS) of less than or equal to 40.
(I)
			 Degree of ambulation-Mainly in bed
(II) Activity/extent of disease-not able to
			 do work; extensive disease
(III)
			 Ability to do self-care -Mainly Assistance
(IV) Food/fluid intake-Normal to
			 reduced
(V) State of consciousness
			 -Either fully conscious or drowsy/confused
(ii) Inability to maintain hydration and
			 caloric intake with any one of the following:
(I) Weight loss greater than 10% during
			 previous 3 months
(II) Weight loss
			 greater than 7.5% in previous 6 weeks
(III) Serum albumin less than 2.5
			 gm/dl
(IV) Current history of
			 pulmonary aspiration without effective response to speech language pathology
			 interventions to improve dysphagia and decrease aspiration events.
(V) Calorie counts documenting inadequate
			 caloric/fluid intake. (Patient's height and weight-caloric intake is too low to
			 maintain normal BMI or fewer calories than necessary to maintain normal BMI -
			 determine with caloric counts)
(VI)
			 Dysphagia severe enough to prevent the patient from receiving food and fluids
			 necessary to sustain life in a patient who declines or does not receive
			 artificial nutrition and hydration.
(iii) The medical criteria for 3 listed below
			 would support a terminal prognosis for individuals with a diagnosis of coma
			 (any etiology):
(I) Comatose patients with any
			 3 of the following on day three or after of coma:
I. abnormal brain stem response
II. absent verbal response
III. absent withdrawal response to
			 pain
IV. increase in serum
			 creatinine greater than 1.5 mg/dl
3. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits
(f)
Hospice Criteria for Adult
			 Amyotrophic Lateral Sclerosis (ALS)
1.
			 Terminal Illness Description: An individual is considered to be terminally ill
			 if the medical prognosis indicates a life expectancy of six months or
			 less.
2. Criteria for initial
			 certification: Criteria below must be present at the time of
initial
			 certification
for hospice. ALS tends to progress in a linear fashion
			 over time. The
overall
rate of decline in each patient is
			 fairly constant and predictable, unlike many other non-cancer diseases. No
single
variable deteriorates at a uniform rate in all
			 patients. Therefore, multiple clinical parameters are required to judge the
			 progression of ALS. Although ALS usually presents in a localized anatomical
			 area, the location of initial presentation does not correlate with survival
			 time. By the time patients become end-stage, muscle denervation has become
			 widespread, affecting all areas of the body, and initial predominance patterns
			 do not persist. In end-stage ALS, two factors are critical in determining
			 prognosis: ability to breathe, and to a lesser extent ability to swallow. The
			 former can be managed by artificial ventilation, and the latter by gastrostomy
			 or other artificial feeding, unless the patient has recurrent aspiration
			 pneumonia. While not necessarily a contraindication to hospice care, the
			 decision to institute either artificial ventilation or artificial feeding will
			 significantly alter six-month prognosis. Examination by a neurologist within
			 three months of assessment for hospice is required, both to confirm the
			 diagnosis and to assist with prognosis. Patients will be considered to be in
			 the terminal stage of ALS (life expectancy of six months or less) if they meet
			 the following criteria (must fulfill
i, ii,
or
iii
):
(i) The patient must
			 demonstrate critically impaired breathing capacity
(I) Critically impaired breathing capacity as
			 demonstrated by
all
the following characteristics occurring
			 within the 12 months preceding initial hospice certification:
I. Vital capacity (VC) less than 30% of
			 normal
II. Continuous dyspnea at
			 rest
III. Hypoxemia at rest on room
			 air, with a current ABG PO2 at or below 59mm HG or oxygen saturation at or
			 below 89%
IV. Patient declines
			 artificial ventilation
(ii) Patient must demonstrate
both
rapid progression of ALS and critical nutritional
			 impairment
(I) Rapid progression of ALS as
			 demonstrated by
all
the following characteristics occurring
			 within the 12 months preceding initial hospice certification:
I. Progression from independent ambulation to
			 wheelchair or bed bound status
II.
			 Progression from normal to barely intelligible or unintelligible
			 speech
III. Progression from normal
			 to pureed diet
IV. Progression from
			 independence in most or all activities of daily living (ADLs) to needing major
			 assistance by caretaker in
all
ADLs.
(II) Critical nutritional impairment as
			 demonstrated by
all
the following characteristics occurring
			 within the 12 months preceding initial hospice certification:
I. Oral intake of nutrients and fluids
			 insufficient to sustain life
II.
			 Unintentional progressive weight loss of greater than 10% of body weight over
			 the preceding six months.
(iii) Patient must demonstrate
both
rapid progression of ALS and life-threatening
			 complications
(I) Rapid progression of ALS,
			 see (ii) (I) above
(II)
			 Life-threatening complications as demonstrated by one of the following
			 characteristics occurring within the 12 months preceding initial hospice
			 certification:
I. Two or more episodes of
			 recurrent aspiration pneumonia (with or without tube feedings)
II. Upper urinary tract infection
			 (pyelonephritis) Sepsis
III. Other
			 medical complications not identified above will be reviewed on a case-by-case
			 basis with appropriate medical justification
3. Criteria for recertification:
			 Criteria below must be present at the time of
recertification
for
			 hospice. Patients will be considered to be in the terminal stage of their
			 illness (life expectancy of six months or less) if they meet (i) and (ii)
			 below:
(i) The patient must demonstrate
			 critically impaired breathing capacity
(I)
			 Critically impaired breathing capacity as demonstrated by
all
the following characteristics:
I. Continuous
			 dyspnea at rest
II. Hypoxemia at
			 rest on room air with a current ABG PO2 at or below 59 mm Hg or oxygen
			 saturation at or below 89%
III.
			 Patient declines artificial ventilation
(ii) Patient must demonstrate rapid
			 progression of ALS and at least one life-threatening complication.
(I) Life-threatening complications as
			 demonstrated by one of the following characteristics:
I. Two or more episodes of recurrent
			 aspiration pneumonia (with or without tube feedings)
II. Upper urinary tract infection
			 (pyelonephritis) Sepsis
III. Other
			 medical complications not identified above will be reviewed on a case-by-case
			 basis with appropriate medical justification
4. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits
(g)
Hospice Criteria for Adult
			 Cancer
1. Terminal Illness
			 Description: An individual is considered to be terminally ill if the medical
			 prognosis indicates a life expectancy of six months or less.
2. Criteria for initial certification or
			 recertification: Criteria below must be present at the time of
initial
			 certification or re-certification
for hospice. Patients will be
			 considered to be in the terminal stage of cancer (life expectancy of six months
			 or less) if (
i
)
or (ii)
below are present:
(i) Documentation of metastasis or final
			 disease stage is required with evidence of progression as documented by
			 worsening clinical status, symptoms, signs and/or laboratory results.
(ii) Progression from an earlier stage of
			 disease to metastatic disease with either:
(I)
			 A continued decline in spite of therapy, that is, aggressive treatment,
			 or
(II) Patient declines further
			 disease directed therapy.
3. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits
(h)
Hospice Criteria for Adult Heart
			 Disease
1. Terminal Illness
			 Description: An individual is considered to be terminally ill if the medical
			 prognosis indicates a life expectancy of six months or less.
2. Criteria for initial certification or
			 recertification: Criteria below must be present at the time of
initial
			 certification or re-certification
for hospice. The medical criteria
			 listed below would support a terminal prognosis for individuals with a
			 diagnosis of heart disease. Medical criteria
(i) and (ii)
must be
			 present as they are important indications of the severity of heart disease and
			 would thus support a terminal prognosis if met.
(i) When the patient is approved or
			 recertified, the patient must already be optimally treated with Beta Blockers,
			 diuretics,
and
vasodilators, which may include
			 AngiotensinConverting Enzymes (ACE) inhibitors or Angiotensin Receptive
			 Blockers (ARBs) for a diagnosis of Heart Failure. This paragraph does not need
			 to be satisfied if any of the following conditions are documented in the
			 medical record and present at the time of certification or recertification:
(I) Side effects, such as hypotension or
			 hyperkalemia;
or
(II)
			 Evidence of treatment failure of ACE inhibitors, ARBs, or a combination of
			 hydralazine and nitrates; or
(III)
			 The patient voluntarily declines treatment.
(ii) The patient has significant symptoms of
			 recurrent heart failure at rest,
and
is classified as a New York
			 Heart Association (NYHA) Class IV:
(I) Unable
			 to carry on any physical activity without symptoms
(II) Symptoms are present even at
			 rest
(III) If any physical activity
			 is undertaken, symptoms are increased
(iii) Documentation of the following factors
			 may provide additional support for end stage heart disease:
(I) Treatment resistant symptomatic
			 supraventricular or ventricular arrhythmias
(II) History of cardiac arrest or
			 resuscitation
(III) History of
			 unexplained syncope
(IV) Brain
			 embolism of cardiac origin
(V)
			 Concomitant HIV disease
(VI)
			 Documentation of ejection fraction of 20% or less
(VII) Angina pectoris, at rest
(iv) The use of IV Milrinone or
			 Dobutamine does not limit initial certification or recertification of hospice
			 if it is considered palliative and is not likely to change the terminal
			 prognosis of the patient.
3. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits
(i)
Hospice Criteria for Adult Liver
			 Disease
1. Terminal Illness
			 Description: Coverage of hospice care depends upon a physician's certification
			 of an individual's prognosis of a life expectancy of six months or less if the
			 terminal illness runs its normal course.
2. Criteria for initial certification and
			 recertification: Criteria below must be present at the time of
initial
			 certification/recertification
for hospice. 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. Documentation in the record must
			 support both
(i) and (ii)
.
(i)
			 Documentation of progression with active decline as evidenced by worsening
			 clinical status, symptoms, signs and laboratory results. The patient's terminal
			 condition must be supported by one or more of the items below:
(I) Clinical Status
I. Recurrent or intractable infections such
			 as pneumonia, sepsis or upper urinary tract.
II. Documented progressive
			 inanition.
(II) Symptoms
I. Dyspnea with increasing respiratory
			 rate
II. Nausea/vomiting poorly
			 responsive to treatment
III.
			 Diarrhea, intractable
IV. Pain
			 requiring increasing doses of major analgesics more than briefly.
(III) Signs
I. Ascites
II. Edema
III. Weakness
IV. Change in level of
			 consciousness
(IV)
			 Laboratory (When available. Lab testing is not required to establish hospice
			 eligibility.)
I. Increasing pCO2 or
			 decreasing pO2 or decreasing SaO2
II. Increasing liver function
			 studies
III. Progressively
			 decreasing or increasing serum sodium
(V) Decline in Karnofsky Performance Status
			 (KPS) or Palliative Performance Score (PPS) due to progression of
			 disease.
(VI) Progression to
			 dependence on assistance with additional activities of daily living.
(VII) History of increasing ER visits,
			 hospitalizations, or physician visits related to the hospice primary diagnosis
			 prior to election of the hospice benefit.
(ii) End stage liver disease is present and
			 the patient shows at least
one
of the following:
(I) ascites, refractory to treatment or
			 patient non-complaint
(II)
			 spontaneous bacterial peritonitis
(III) hepatorenal syndrome (elevated serum
			 creatinine and BUN with oliguria (< 400ml/day) and urine sodium
			 concentration less than10 mEq/l
(IV) hepatic encephalopathy, refractory to
			 treatment, or patient non-compliant
(V) recurrent variceal bleeding, despite
			 intensive therapy
(iii)
			 Documentation of the following factors will also support eligibility for
			 hospice care:
(I) progressive
			 malnutrition
(II) muscle wasting
			 with reduced strength and endurance
(III) continued active alcoholism (>80 gm
			 ethanol/day)
(IV) hepatocellular
			 carcinoma
(V) HBsAg (Hepatitis B)
			 positivity
(VI) Hepatitis C
			 refractory to interferon treatment
3. Reasons for Denial
(i) Patients not meeting the specific medical
			 criteria in this policy.
(ii)
			 Absence of supporting documentation of progression or rapid decline.
(iii) Failure to document terminal status of
			 six months or less.
(iv) Patient is
			 not eligible for full Medicaid benefits
(j)
Hospice Criteria for Adult Renal
			 Disease
1. Terminal Illness
			 Description: An individual is considered to be terminally ill if the medical
			 prognosis indicates a life expectancy of six months or less.
2. Criteria for initial certification:
			 Criteria below must be present at the time of
initial
			 certification
for hospice. 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:
(i)
Acute
			 renal failure
(
I) and (II)
must be present)
(I) Creatinine clearance less than 10 cc/min
			 (less than 15 cc/min. for diabetes)
(II) Serum creatinine greater than 8.0 mg/dl
			 (greater than 6.0 mg/dl for diabetes)
(ii)
Chronic renal failure (
I),
			 (II), and (III) must be present)
(I)
			 Creatinine clearance less than 10 cc/min (less than 15cc/min for
			 diabetes)
(II) Serum creatinine
			 greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes)
(III) Glomerular filtration rate (GFR) less
			 than 30 ml/min
3. Criteria for recertification: Criteria
			 below must be present at the time of
recertification
for hospice.
			 Patients will be considered to be in the terminal stage of their illness (life
			 expectancy of six months or less) if they meet the following criteria:
(i)
Chronic renal failure (I), (II), or
			 (III)
must be present)
(I)
			 Creatinine clearance less than 10 cc/min (less than 15cc/min for
			 diabetes)
(II) Serum creatinine
			 greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes)
(III) Glomerular filtration rate (GFR) less
			 than 30 ml/min
4.
			 Reasons for Denial
(i) Patients not meeting
			 the specific medical criteria in this policy.
(ii) Absence of supporting documentation of
			 progression or rapid decline.
(iii)
			 Failure to document terminal status of six months or less.
(iv) Patient is on dialysis.
(iv) Patient is not eligible for full
			 Medicaid benefits