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 dementia (life expectancy of six months or less) if they meet the following criteria. Patients with dementia should show all the following characteristics:
Stage seven or beyond according to the Functional Assessment Staging Scale
Unable to ambulate without assistance;
Unable to dress without assistance;
Unable to bathe without assistance;
Urinary and fecal incontinence, intermittent or constant;
No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words.
Patients should have had one of the following within the past 12 months:
Aspiration pneumonia;
Pyelonephritis or other upper urinary tract infection;
Septicemia;
Decubitus ulcers, multiple, stage 3-4;
Fever, recurrent after antibiotics;
Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5 gm/dl.
Note: This section is specific for Alzheimer’s Disease and related disorders, and is not appropriate for other types of dementia, such as multi-infarct dementia.
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 disease and limited life expectancy.
