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 liver disease (life expectancy of six months or less) if they meet the following criteria. (1 and 2 should be present; factors from 3 will lend supporting documentation.):
The patient should show both a and b:
Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) >1.5;
Serum albumin <2.5 gm/dl
End stage liver disease is present and the patient shows at least one of the following:
Ascites, refractory to treatment or patient non-compliant;
Spontaneous bacterial peritonitis;
Hepatorenal syndrome (elevated creatinine and BUN with oliguria)
Hepatic encephalopathy, refractory to treatment, or patient non-compliant;
Recurrent variceal bleeding, despite intensive therapy.
Documentation of the following factors will support eligibility for hospice care:
Progressive malnutrition;
Muscle wasting with reduced strength and endurance;
Continued active alcoholism (>80 gm ethanol/day);
Hepatocellular carcinoma;
HBsAg (Hepatitis B) positivity;
Hepatitis C refractory to interferon treatment.
Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient should be discharged from hospice.
Important note
Hospice eligibility is determined by a physician based on the patient’s overall condition. Not every patient will meet every criterion listed above, but may still qualify if their condition is consistent with advanced, life-limiting disease.
