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 heart disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present. Factors from 3 will add supporting documentation.):
At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or is not a candidate for a surgical procedure or has declined a procedure. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease.)
The patient is classified as New York Heart Association (NYHA) Class IV and may have significant symptoms of heart failure or angina at rest. (Class IV patients with heart disease have an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal 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.
Documentation of the following factors will support but is not required to establish eligibility for hospice care:
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.
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.
