DISEASE INDICATORS

RENAL DISEASE

Indicators and limitations of coverage and/or necessity

Medicare Qualifications

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.

Acute renal failure 1, 2 and 3 must be present; factors from 4 will lend supporting documentation)

  1. The patient is not seeking dialysis or renal transplant
  2. Creatinine clearance <10 cc/min (<15 cc/min. for diabetes)
  3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)
  4. Comorbid conditions:
  5. Mechanical ventilation
  6. Malignancy (other organ system)
  7. Chronic lung disease
  8. Advanced cardiac disease
  9. Advanced liver disease
  10. Sepsis
  11. Immunosuppression/AIDS
  12. Albumin <3.5 gm/dl
  13. Cachexia
  14. Platelet count <25,000
  15. Disseminated intravascular coagulation
  16. Gastrointestinal bleeding

Chronic renal failure 1, 2 and 3 must be present; factors from 4 will lend supporting documentation

  1. The patient is not seeking dialysis or renal transplant
  2. Creatinine clearance <10 cc/min (<15 cc/min. for diabetes)
  3. Serum creatinine >8.0 mg/dl (>6.9 mg/dl for diabetes)
  4. Signs and symptoms of renal failure:
  5. Uremia
  6. Oliguria (<400 cc/day)
  7. Intractable hyperkalemia (>7.0) not responsive to treatment
  8. Uremic pericarditis
  9. Hepatorenal syndrome
  10. Intractable fluid overload, not responsive to treatment
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