Coverage Guidance
The following criteria are provided directly from Medicare guidelines and are used by physicians to support hospice eligibility.
Patients will be considered to be in the terminal stage of adult failure to thrive (life expectancy of six months or less) if they meet the following criteria:
The patient has significant nutritional impairment as evidenced by:
a. Body mass index (BMI) < 22
b. The patient is declining or not responding to nutritional support
The patient has significant disability as evidenced by:
a. Karnofsky Performance Status (KPS) or Palliative Performance Scale (PPS) ≤ 40%
The patient should demonstrate clinical decline as evidenced by one or more of the following:
a. Progressive weight loss
b. Decreased oral intake
c. Increasing weakness or fatigue
d. Recurrent infections
Important note
Hospice eligibility is determined by a physician based on the patient’s overall clinical condition. Patients may still qualify even if they do not meet every criterion listed above, as long as documentation supports advanced decline and limited life expectancy.
