Coverage Guidance
The following criteria are provided directly from Medicare guidelines and are used by physicians to support hospice eligibility.
Cancer Diagnoses
A. Disease with distant metastases at presentation OR
B. Progression from an earlier stage of disease to metastatic disease with either:
1. a continued decline in spite of therapy
2. patient declines further disease directed therapy
Note: Certain cancers with poor prognoses (e.g. small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section.
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.
