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 their illness (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):
CD4+ Count 100,000 copies/ml, plus one of the following:
CNS lymphoma;
Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass);
Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused;
Progressive multifocal leukoencephalopathy;
Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy;
Visceral Kaposi’s sarcoma unresponsive to therapy;
Renal failure in the absence of dialysis;
Cryptosporidium infection;
Toxoplasmosis, unresponsive to therapy.
Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of ≤50%
Documentation of the following factors will support eligibility for hospice care:
Chronic persistent diarrhea for one year;
Persistent serum albumin <2.5 gm/dl;
Concomitant, active substance abuse;
Age >50 years;
Absence of, or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease;
Advanced AIDS dementia complex;
Toxoplasmosis;
Congestive heart failure, symptomatic at rest;
Advanced liver 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.
