Indicators and limitations of coverage and/or necessity

Medicare/Medicaid Qualifications

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 (1 and 2 must be present; Documentation of 3,4 and/or 5 will lend supporting documentation):

  1. Severe chronic lung disease as documented by both a and b:
  2. Disabling dyspnea at rest, poorly or unresponsive 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, not necessary to obtain for Medicare but IS necessary for Medicaid).
  3. Progression of end stage pulmonary disease, as evidenced by prior increasing visits (six or more within the last 12 months for Medicaid) to the emergency department or prior hospitalizations (two or more for Medicaid) for pulmonary infections and/or respiratory failure (documentation for serial disease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain).

Medicaid Note: Also includes one or more Intensive Care Unit admissions within the last six months. The hospitalizations or emergency room visits must be related to the terminal illness.

  1. Hypoxemia at rest on room air, (Medicaid only: with a current ABG and PO2 at or below 59 mmHg or oxygen saturation at or below 89% taken at rest may be obtained either from recent hospital records or hypercapnia) as evidenced by pO2 greater than or equal to 88% (these values may be obtained from recent hospital records) or hypercapnia, as evidenced by pCO23 50 mmHg (this value may be obtained from recent hospital records).
  2. Cor pulmonale and right heart failure (RHF) secondary or pulmonary disease (e.g., not secondary to left heart disease or valvulopathy).
  3. Unintentional progressive weight loss or greater than 10% of body weight over the preceding six months.
  4. Resting tachycardia >100/min