Indicators and limitations of coverage and/or necessity

Medicare/Medicaid Qualifications

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; factors from 3 will add supporting documentation):

  1. CD4+Count <25 cells/mcL or persistent viral load >100,000 copies/ml, plus one of the following:
  2. CNS lymphoma
  3. Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)
  4. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
  5. Progressive multifocal leukoencephalopathy
  6. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
  7. Visceral Kaposi’s sarcoma unresponsive to therapy
  8. Renal failure in the absence of dialysis
  9. Cryptosporidium infection
  10. Toxoplasmosis, unresponsive to therapy
  11. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of greater than or equal to 50
  12. Documentation of the following factors will support eligibility for hospice care:
  13. Chronic persistent diarrhea for one year
  14. Persistent serum albumin <2.5
  15. Concomitant, active substance abuse (Medicare only)
  16. Age >50 years
  17. Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related
  18. Advance AIDS dementia complex
  19. Toxoplasmosis
  20. Congestive heart failure, symptomatic at rests, New York Heart Association (NYHA) classification Stage IV (Medicaid only)


Documentation Requirements

  1. Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the above criteria would meet this requirement.
  2. If the patient does not meet the above criteria, yet is deemed appropriate for hospice care, sufficient documentation of the patient’s condition that justifies terminal status, in the absence of meeting the above criteria, would be necessary.
  3. Recertification for hospice care requires that the same standards be met for initial.