LCD Guidelines

Patients will be considered to be in the terminal stage of dementia (life expectancy of 6 months or less) if they show all of the following characteristics:

1. Stage 7 or beyond according to the Functional Assessment Staging Scale
2. Unable to ambulate without assistance
3. Unable to dress without assistance
4. Unable to bathe without assistance
5. Urinary & fecal incontinence, intermittent or constant
6. No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words​

Patients should have one of the following within the past 12 months:

1. Aspiration pneumonia
2. Pyelonephritis or other upper urinary tract infection
3. Septicemia
4. Multiple decubitus ulcers, stage 3-4
5. Recurrent fever after antibiotics
6. Inability to maintain sufficient fluid & calorie intake with 10% weight loss during the previous 6 months or serum albumin <2.5 gm/dl

Comparative Data

Fast Score – Document on continually, on admit Fast 7a now 7c
PPS/ADL – PPS score change, 1 month ago PPS 50% now PPS 30%, Patient was 2 person transfer, now requires Hoyer lift
Intake change – Was eating 100% of meals now only eats 50% of meals, Patient is pocketing food, Diet change from regular to pureed, Patient was eating independently but now requires assistance
Weight Change – Lost 10lbs in last month, lost 10% of body weight in last 6 months
Alert/ Oriented – On admission patient was sleeping 10 hours a day, now sleeping 15+ hours a day
Skin Issues – Should be documented on every visit, redness noted to coccyx, previously had no skin issues
Activity – Patient can no longer move themself in wheelchair, could move independently in wheelchair on admission, patient is leaning in wheelchair and now requires lateral support
Infections – New and/or recurrent infection(s)
Fever – Recurrent fever

Comorbidities

LCD Guidelines

1. Disease with distant metastases at presentation

OR

2. Progression from an earlier stage of disease to metastatic disease with either:

• continued decline despite therapy
• patient declines further disease directed therapy

NOTE: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer & pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.

Comparative Data

Increase in Tumor Size – Tumor was size of golf ball, now is size of softball
Decease in activity – Was able to go out & enjoy activity, now staying in room
Comorbidities – CHF, COPD, etc.
Decrease in intake – Was eating 100% of meals 1 month ago, now eating only 1 meal per day, complains of change in taste, weight change, anorexia
Depression & Anxiety – Was very social interacting with people, now staying in room, not talkative
Medication changes – Needs depression & anxiety medications
Increase in Pain – Change in pain intensity, pain interferes with activity
Change in ADL’s – Needs assistance with bathing & dressing, PPS was 60% 2 months ago from today, PPS 40%, increased weakness
Change in skin – Pallor, lesions, wounds, nonhealing wounds, dusky, bruising

Comorbidities

LCD Guidelines

(1 & 2 are required, 3 will act as supporting documentation.)

1. At the time of certification/ recertification for hospice, the patient is or already has been optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. (Optimally treated = patients not on vasodilators have medical reason for refusing drugs, e.g. hypotension or renal disease.)
2. The patient is classified as New York Heart Association (NYHA) Class IV & may have significant symptoms of heart failure or angina at rest. (Class IV patients w/ heart disease have an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the angina syndrome may be present even at rest. If any physical activity is undertaken discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of ≤20% but is not required if not already available.
3. The following factors are not required for hospice eligibility but act as supporting documentation:

• Treatment resistant symptomatic supraventricular or ventricular arrhythmias
• History of cardiac arrest or resuscitation
• History of unexplained syncope
• Brain embolism of cardiac origin
• Concomitant HIV disease

Comparative Data

Change in Activity – Patient was going to activity daily now stays in room, Was able to walk down the hall now unable to walk more than 5 feet
Change in Breathing – Patient is now using purse lip breathing, labored breathing
Increase in SOB – Patient was able to walk down the hallway without oxygen, Patient is now using oxygen & is only able to ambulate 15 feet without resting
Pain – Increase in pain medications, chest pain noted with activity
Anxiety – Patient gets very anxious when short of breath, Patient states “I get very nervous when I can’t breathe”
Edema – Previously no edema, now edema is present in feet & ankles
Change in weight – Patient has gained 5lbs in 5 days related to edema
Depression – Patient is withdrawn, does not engage in activity
Intake – Patient complains of feeling full but is only eating 25% of meal, Patient was eating 100% of meal & now only eating 50%
Change in ADL’s – Patient was previously stand by assist w/ bathing; now is a 1 person assist
Medication changes – We have changed Lasix every week

Comorbidities

LCD Guidelines

(1 of the following criteria must be met)

1. Severely impaired breathing capacity w/ all of the findings: Dyspnea at rest vital capacity less than 30%, the requirement of supplemental oxygen at rest, the patient declines artificial ventilation

OR

2. Rapid disease progression & either A or B below:

• Progression from independent ambulation to wheelchair or bedbound status
• Progression from normal to barely intelligible or unintelligible speech
• Progression from normal to pureed diet
• Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs

AND 

A. Severe nutritional impairment demonstrated by all of the following in the preceding 12 months: oral intake of nutrients & fluids insufficient to sustain life continuing weight loss dehydration or hypovolemia absence of artificial feeding

OR

B. Life-threatening complications demonstrated by 1 or more of the following in the preceding 12 months: Recurrent aspiration pneumonia (w/ or without tube feedings), Upper urinary tract infection (e.g. Pyelonephritis), Sepsis, Recurrent fever after antibiotic therapy, Stage 3 or 4 decubitus ulcer(s)

Rapid decline or Comorbidities may support eligibility in the absence of the above criteria.

Comparative Data

Fast Score – On admission Fast 7a now 7c
PPS/ADL – On admission PPS 50%, now PPS 40%
Intake – Was eating 100% of meals now only eats 50% of meals, Patient is pocketing food, Diet change from regular to pureed, Patient was eating independently but now needing cues to eat
Weight Change – Lost 10lbs since admission
Alert/ Oriented – On admission patient was sleeping 10 hours a day, now sleeping 15+ hours a day, patient has become combative w/ care, needs medication intervention for behaviors
Skin Issues – Should be documented on every visit, redness noted to coccyx, previously had no skin issues
Activity – Patient can no longer move themself in wheelchair, could move independently in wheelchair on admission, patient is leaning in wheelchair and now requires lateral support
Infections – New and/or recurrent infection(s)
Fever – Recurrent fever

Comorbidities

LCD Guidelines

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 & 2 should be present. Documentation of 3, 4, & 5 will be supporting documentation.)

1. Severe chronic lung disease as documented by:

A. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators resulting in decreased functional capacity. e.g. bed to chair existence, fatigue, & cough. (Documentation of Forced Expiratory Volume in 1 second (FEV1) after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.)

Comparative Data

Change in Breathing – Labored purse lip breathing, barrel chest noted, cough noted, tripod posture
Increase in SOB – Not able to ambulate or handle activity, patient used to be able to walk to bathroom not short of breath and now requires a break, does not sleep in bed anymore, prefers a recliner to sleep in
Change in Activity – Used to be involved with every activity, now does not attend activities
Change in Intake – Patient was eating 100% now only eating 50%
Infection – Pneumonia, bronchitis
Comorbidities – Increase in CHF exacerbation’s

Comorbidities

LCD Guidelines

(1 & either 2 or 3 should be present.)

1. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis
2. Creatine clearance <10 cc/min (15 cc/min for diabetics) based on measurement or calculation; or <15 cc/min (<20 cc/min for diabetics) with comorbidity of congestive heart failure
3. Serum creatine >8.0 mg/dl (>6.0 mg/ dl for diabetics)

Comorbidities:

• History of mechanical ventilation
• Chronic lung disease
• Advanced liver disease
• Immunosuppression/ AIDS
• Cachexia
• Disseminated intravascular coagulation
• ​Malignancy (other organ system)
• Advanced cardiac disease
• Sepsis
• Albumin <3.5 gm/dl
• Platelet count <25,000
• Gastrointestinal bleeding

Chronic Renal Failure (1 & either 2 or 3 should be present.)

1. The patient is not seeking dialysis or renal transplant, or is discontinuing dialysis
2. Creatinine clearance <10 cc/min (<15 cc/min for diabetics) based on measurement or calculation; or <15 cc/min (<20 cc/min for diabetics) with comorbidity of CHF
3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics)

Signs & Symptoms:

• Uremia w/ altered level of consciousness
• Uremic pericarditis
• Intractable hyperkalemia (>7.0)
• Intractable fluid overload
• Oliguria (<400 cc/24 hours)
• Hepatorenal Syndrome

Comparative Data

Fast Score – Document on continually, on admit Fast 7a now 7c
PPS/ADL – PPS score change, 1 month ago PPS 50% now PPS 30%, Patient was 2 person transfer, now requires Hoyer lift
Intake change – Was eating 100% of meals now only eats 50% of meals, Patient is pocketing food, Diet change from regular to pureed, Patient was eating independently but now requires assistance
Weight Change – Lost 10lbs in last month, lost 10% of body weight in last 6 months
Alert/ Oriented – On admission patient was sleeping 10 hours a day, now sleeping 15+ hours a day
Skin Issues – Should be documented on every visit, redness noted to coccyx, previously had no skin issues
Activity – Patient can no longer move themself in wheelchair, could move independently in wheelchair on admission, patient is leaning in wheelchair and now requires lateral support
Infections – New and/or recurrent infection(s)
Fever – Recurrent fever

Comorbidities