DISEASE INDICATORS

LIVER DISEASE

Indicators and limitations of coverage and/or necessity

Medicare Qualifications

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 (1 and 2 must be present; factors 3 will lend supporting documentation).

  1. The patient should show both a and b:
  2. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)>1.5
  3. Serum albumin <2.5gm/dl
  4. End stage liver disease if present and the patient shows at least one of the following:
  5. Ascites, refractory to treatment or patient non-complaint
  6. Spontaneous bacterial peritonitis
  7. Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10 mEq/1
  8. Hepatic encephalopathy, refractory to treatment or patient non-complaint
  9. Recurrent variceal bleeding, despite intensive therapy
  10. Documentation of the following factors will support eligibility for hospice care:
  11. Progressive malnutrition
  12. Muscle wasting with reduced strength and endurance
  13. Continued active alcoholism (>80 gm/ethanol/day)
  14. Hepatocellular carcinoma
  15. HBsAg (Hepatitis B) positivity
  16. Hepatitis C refractory to interferon treatment
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