Clinical Policy: Hospice Services

Reference Number: CP.MP.54
Date of Last Revision: 06/25

Coding Implications
Revision Log

See Important Reminder at the end of this policy for important regulatory and legal information.

Description
Hospice is a coordinated, integrated program developed by a multidisciplinary team of professionals to provide end-of-life care primarily focused on relieving pain and symptoms specifically related to the terminal diagnosis of members/enrollees with a life expectancy of six months or less. This policy describes the medical necessity criteria for hospice services.

Policy
Initial Request
It is the policy of health plans associated with Centene Corporation® that hospice is considered medically necessary when the requirements in Criteria sections I, II, and III are met:

I. The Required Documentation has been submitted, and
II. The member/enrollee meets one of the severity of illness criterion:
A. Cancer;
B. ALS;
C. Heart Disease;
D. Pulmonary Disease;
E. Dementia;
F. HIV;
G. Liver Failure;
H. Acute or Chronic Renal Failure;
I. Stroke;
J. Coma;
K. Non-Disease Specific Decline in Clinical Status.
III. The requested intensity of service is appropriate for one of the following:
A. Routine Hospice Home Care;
B. Continuous Hospice Home Care;
C. Inpatient Respite Hospice Care;
D. General Inpatient, Short Term (non-respite) Hospice Care.
IV. Not Medically Necessary Services

Note: Hospice room and board (long-term care/nursing home) coverage is based on the Benefit Plan Contract.

Criteria

II. Severity of Illness
The presence of significant comorbidities should be considered when using these criteria to determine hospice appropriateness.

A. Cancer – meets all of the following:

1. Palliative performance scale (PPS) (Appendix A) or Karnofsky performance status scale (KPS) (Appendix B) score < 70%;
2. Dependence for at least two activities of daily living (ADLs) (e.g. ambulation, continence, transfers, dressing, feeding, bathing);
3. Disease status is one of the following:
   a. Metastatic cancer at presentation, deferring therapy,
   b. Progression to metastatic disease with decline despite therapy or deferring therapy,
   c. Brain, pancreatic, or small cell lung cancer;
   B. ALS (amyotrophic lateral sclerosis) – meets all of the following:
4. PPS (Appendix A) or KPS (Appendix B) score < 70%;
5. Dependence for at least two ADLs (e.g. ambulation, continence, transfers, dressing, feeding, bathing);
6. Disease status is one of the following:
   a. Signs or symptoms of impaired respiratory function, not electing tracheostomy or invasive ventilation, and forced vital capacity (FVC) < 30% (if results available);
   b. Rapid progression with critical nutritional impairment indicated by at least 5% loss of body weight (with or without tube feeding);
   c. Rapid progression with other life-threatening complications (sepsis, recurrent aspiration, pyelonephritis, stage 3-4 decubiti);
   C. Heart Disease – meets all of the following:
7. PPS (Appendix A) or KPS (Appendix B) score < 70%;
8. Dependence for at least two ADLs (e.g. ambulation, continence, transfers, dressing, feeding, bathing);
9. Disease status is one of the following:
   a. Congestive Heart Failure (CHF), both of the following:
   i. Symptomatic at rest (NYHA Class IV), with ejection fraction (EF) ≤ 20% (if results available);
   ii. Presently optimally treated with diuretics and vasodilators or has failed therapy with IV inotropes;
   b. Coronary Artery Disease (CAD), all of the following:
   i. Elderly member/enrollee with intractable angina who is not a candidate for coronary revascularization;
   ii. No longer responding well to nitrates, beta- and calcium-channel blockers and other appropriate medications;

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iii. Not a candidate for cardiac transplant;
D. Pulmonary Disease – has fixed obstructive disease OR restrictive disease and meets all of the following:

1. PPS (Appendix A) or KPS (Appendix B) score < 70%;
2. Dependence for at least two ADLs (e.g. ambulation, continence, transfers, dressing, feeding, bathing);
3. Severity, all:
   a. Disabling symptoms at rest or with minimal exertion;
   b. Diminished functional capacity, e.g., bed-to-chair existence;
   c. Forced expiratory volume in 1 second (FEV1) < 30% predicted, after bronchodilator (if able to obtain);
4. Progressiveness, both:
   a. Two ED visits in prior six months or one hospitalization in last year for pulmonary infection and/or respiratory failure with intubation or BiPAP (bi-level positive airway pressure);
   b. Member/enrollee states they do not want to be intubated;
5. Partial pressure of oxygen in arterial blood (PaO2) ≤ 55 mmHg or arterial oxygen saturation (SaO2) ≤ 88% at rest on room air; or partial pressure of carbon dioxide in arterial blood (PaCO2) ≥ 50 mmHg;
   E. Dementia – meets all of the following:
6. Increasing severity indicated by FAST (Appendix C) stage 7 or beyond; and
7. Increasing medical complications indicated by one of the following in the past 12 months:
   a. Aspiration pneumonia;
   b. Pyelonephritis or other upper urinary tract infection;
   c. Septicemia;
   d. Multiple stage 3-4 decubiti;
   e. Fever recurrent after a course of antibiotics;
   f. Weight loss > 10% during the previous six months;
   g. Albumin < 2.5 g/dl;
   F. HIV – meets all of the following:
8. CD4+ (T-cell) count < 25 or viral load > 100,000 copies/ml;
9. PPS or KPS score < 50%;
10. At least one of the following AIDS-related conditions:
    a. Central nervous system or poorly responsive systemic lymphoma;
    b. Wasting: loss of at least 10% lean body mass;
    c. Mycobacterium avium complex (MAC) bacteremia;
    d. Progressive multifocal leukoencephalopathy (PML);
    e. Refractory visceral Kaposi’s sarcoma (KS);
    f. Renal failure in the absence of dialysis;
    g. Refractory cryptosporidium infection;
    h. Refractory toxoplasmosis;
    G. Liver Disease – meets all of the following:
11. PPS (Appendix A) or KPS (Appendix B) score < 70%;
12. Dependence for at least two ADLs (e.g. ambulation, continence, transfers, dressing, feeding, bathing);

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3. Member/enrollee has end-stage liver disease and is not on the transplant list;
4. Prothrombin time (PT) > five seconds or International Normalized Ration (INR) > 1.5;
5. Albumin < 2.5 g/dl;
6. And at least one of the following:
   a. Recurrent bleeding esophageal varices despite therapy;
   b. Refractory ascites;
   c. Episode of spontaneous bacterial peritonitis;
   d. Hepatorenal syndrome;
   e. Hepatic encephalopathy;
   H. Acute or Chronic Renal Failure – meets all of the following:
7. PPS (Appendix A) or KPS (Appendix B) score < 70%;
8. Dependence for at least two ADLs (e.g. ambulation, continence, transfers, dressing, feeding, bathing);
9. Member/enrollee is in renal failure, not receiving dialysis and one of the following:
   a. Serum Creatinine > 8 mg/dl (> 6 diabetes);
   b. Creatinine clearance < 15 ml/minute;
   I. Stroke – meets all of the following:
10. PPS or KPS < 40%;
11. Inadequate oral intake with one of the following:
    a. Weight loss of > 10% body weight in the last six months, or > 7.5% in to the last three months;
    b. Serum albumin < 2.5 g/dl;
    c. Recurrent aspiration;
    d. Dysphagia and declining tube feeding and hydration;
    J. Coma – member/enrollee is comatose with at least three of the following on day three of coma:
12. Abnormal brain stem response;
13. Absent verbal response;
14. Absent withdrawal to painful stimuli;
15. Creatinine > 1.5 mg/dl;
    K. Non-Disease Specific Decline in Clinical Status (the presence of significant comorbidities should be considered when using these criteria), all of the following:
16. Irreversible decline, based on both baseline and follow-up determinations; and
17. Clinical deterioration of one or more of the following:
    a. Progressive dependence for ADLs;
    b. KPS or PPS score < 70%;
    c. Increasing frequency of ER visits or hospitalizations;
    d. Worsening of one or more of the following:
    i. Clinical status - such as recurrent infections, inanition with progressive weight loss, dysphagia, or decreasing albumin;
    ii. Signs - such as hypotension, ascites, edema, pleural or pericardial disease, or decreased consciousness;
    iii. Symptoms - such as intractable dyspnea, cough, nausea, diarrhea, or pain;
    iv. Laboratory results - arterial blood gases, tumor markers, electrolytes, creatinine, or liver function tests;

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e. Progressive or stage 3 to 4 decubiti.

III. Intensity Of Service (Level Of Care)
The level of care and the dates of service requested must be specified. Only one level of care may be authorized for each day of hospice care provided to an eligible member/enrollee. The appropriate HCPCS or revenue (rev) code must be billed according to applicable contract provisions.

A. Routine Hospice Home Care (HCPCS T2042 or rev code 0651)
Routine hospice home care is medically necessary when < eight hours of nursing care, which may be intermittent, is required in a 24-hour period. 90 days of routine hospice care may be approved.
B. Continuous Hospice Home Care (HCPCS T2043 or rev code 0652)
Continuous hospice home care is medically necessary to maintain the member/enrollee at home when the member/enrollee requires ≥ eight hours of nursing care in a 24-hour period (begins and ends at midnight). Up to five days of continuous home hospice care may be approved with ongoing concurrent review for additional days requested.
C. Inpatient Respite Hospice Care (HCPCS T2044 or rev code 0655)
Respite hospice care is medically necessary to relieve family members/enrollees or other primary caregivers of care duties for no more than five consecutive days per episode. Respite care is short-term inpatient care, and not residential or custodial care. Up to five days per episode of inpatient respite care may be approved.
D. General Inpatient, Short Term (non-respite) Hospice Care (HCPCS T2045 or rev code 0656)

1. General inpatient, short term care services are medically necessary when the intensity or scope of care needed during an acute crisis is not feasible in the home setting and requires frequent adjustment by the member/enrollee’s care team;
2. The individual treatment plan is specifically directed at acute symptom management and/or pain control.
   Up to five days of general inpatient, short term care may be approved with ongoing concurrent review for additional days requested.

IV. Not Medically Necessary Services
Hospice services are considered NOT medically necessary under the following circumstances:
A. Members/enrollees with any of the following as the primary diagnosis:

1. Debility or unspecified debility;
2. Failure to thrive;
   B. The member/enrollee is no longer considered terminally ill as evidenced by a review of the medical documentation;
   C. Services, supplies or procedures that are directed towards curing the terminal condition, except for children covered under Medicaid or CHIP;
   D. Member/enrollee chooses to revoke the hospice election by submitting a signed, written statement with the effective date of the revocation;
   E. Member/enrollee is discharged from hospice services; e.g. member/enrollee is no longer considered terminally ill, member/enrollee refuses services or is uncooperative, moves out of the area, or transfers to a non-covered hospice program. In the event a

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member/enrollee is discharged from hospice, benefit coverage would be available as long as the member/enrollee remained eligible for coverage of medical services.

Subsequent Requests
Authorization is required for each change in the level of intensity of service. Only one level of care may be authorized for each day of hospice care provided to an eligible member/enrollee. The appropriate HCPCS or revenue (rev) code must be billed according to applicable contract provisions.

It is the policy of health plans associated with Centene Corporation that subsequent requests for hospice are medically necessary when meeting one of the following:

1. Request for continuation of routine home care for subsequent recertification period
   Continuation of home care for subsequent recertification periods is medically necessary for additional 90-day periods following submission from a renewed hospice medical director certification of terminal illness.
   II. Change to a higher intensity of service from routine hospice, one of the following:
   A. Continuous Hospice Home Care (HCPCS T2043 or rev code 0652)
   Continuous hospice home care is medically necessary to maintain the member/enrollee at home when the member/enrollee requires ≥ eight hours of nursing care in a 24-hour period (begins and ends at midnight). Up to five days of continuous home hospice care may be approved with ongoing concurrent review for additional days requested.
   B. Inpatient Respite Hospice Care (HCPCS T2044 or rev code 0655)
   Respite hospice care is medically necessary to relieve family members/enrollees or other primary caregivers of care duties for no more than five consecutive days per episode. Respite care is short-term inpatient care, and not residential or custodial care. Up to five days per episode of inpatient respite care may be approved.
   C. General Inpatient, Short Term (non-respite) Hospice Care (HCPCS T2045 or rev code 0656), meets both:
2. The intensity or scope of care needed during an acute crisis is not feasible in the home setting and requires frequent adjustment by the member/enrollee’s care team;
3. The treatment plan is specifically directed at acute symptom management and/or pain control.
   Up to five days of general inpatient, short term care may be approved with ongoing concurrent review for additional days requested.
   III. Change to routine home care following higher intensity of service
   Continuation of routine home care following a higher level of care is medically necessary for the duration of the current 90-day certification period.

Definitions
Levels of Care - four distinct levels of care are available
A. Routine Hospice Home Care
Routine hospice home care is care provided in the member/enrollee’s home and is related to the terminal diagnosis and plan of care written for the member/enrollee. Routine hospice home care may include up to 8 hours of skilled nursing care in a 24-hour period. This care may be provided in a private residence, hospice residential care facility, nursing facility, or an adult care home.
B. Continuous Hospice Home Care

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Continuous hospice home care consists primarily of skilled nursing care at home during brief periods of crisis in order to achieve palliation or management of acute medical symptoms and only as necessary to maintain the member/enrollee at home. Continuous care must provide a minimum of eight hours of nursing care in a 24-hour period, which begins and ends at midnight; the nursing care need not be continuous. Continuous care may be supplemented by home health aide or homemaker services, but at least 50% of the total care must be provided by a nurse, and the care required must be predominantly nursing, rather than personal care or assistance with activities of daily living. Continuous hospice home care is not intended to be respite care or an alternative to paid caregivers or placement in another setting. Continuous hospice home care may include any of the services outlined in the covered services definition below.
C. Inpatient Respite Hospice Care
Short-term inpatient respite hospice care is provided in an approved inpatient hospice facility, hospital or nursing home for no more than five consecutive days per episode. It is allowed to relieve family members/enrollees or other primary caregivers of the primary caregiving duties. A primary caregiver is an individual, designated by the member/enrollee, who is responsible for the 24-hour care and support of the member/enrollee in his or her home. A primary caregiver is not required to elect hospice if it has been determined by the hospice team that the member/enrollee is safe at home alone at the time of the election.
D. General Inpatient, Short Term (non-respite) Hospice Care
General inpatient care, under the hospice benefit, is short-term, non-respite hospice care and is appropriate when used in an approved hospice facility, hospital or nursing home. It is specifically used for pain control and symptom relief which is related to the terminal diagnosis and cannot be managed in the home hospice setting. The goal is to stabilize the member/enrollee and return him/her to the home environment. General inpatient, short-term hospice care may include any of the services outlined in the covered services definition below.

Certification Periods
Certification (benefit) periods include an initial 90-day benefit period, followed by a second, 90-day benefit period, followed by an unlimited number of 60-day benefit periods. Hospice care is continuous from one period to another, unless the member/enrollee revokes, or the hospice provider discharges or does not recertify.

Discontinuation of Hospice
If a member/enrollee revokes or is discharged from hospice care, the remaining days in the benefit period are lost. If/when the member/enrollee meets the hospice coverage requirements, they can re-elect the hospice benefit, and will begin with the next benefit period.

Covered Services
When the above coverage criteria are met, the following hospice care services may be covered as part of the hospice treatment plan:
A. Physician services;
B. Appropriate skilled nursing services;
C. Home health aide services;

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D. Physical and/or occupational therapy;
E. Speech therapy services for dysphagia/feeding therapy;
F. Medical social services;
G. Counseling services (e.g., dietary, bereavement);
H. Short-term inpatient care;
I. Prescription drugs (all drugs and biologics that are necessary for the palliation and management of the terminal illness and related conditions);
J. Consumable medical supplies (e.g., bandages, catheters) used by the hospice team.

Non-covered Services
The following services are considered not covered as part of the hospice treatment plan:
A. Services during an acute inpatient stay for a diagnosis that is unrelated to the terminal illness for which the member/enrollee is receiving hospice care;
B. Services for individuals no longer considered terminally ill;
C. Services, supplies or procedures, or medication that are directed towards curing the terminal condition, except for children enrolled in Medicaid or CHIP who are receiving concurrent care;
D. Services to primarily aid in the performance of activities of daily living;
E. Nutritional supplements, vitamins, minerals and non-prescription drugs;
F. Medical supplies unrelated to the palliative care to be provided;
G. Services for which any other benefits apply.

Provider Responsibilities
Responsibilities of the hospice provider include:
A. Verifying member/enrollee eligibility;
B. Obtaining authorization to provide hospice services before hospice care is initiated;
C. Notifying the health plan of any significant change in the member/enrollee’s status or condition including revisions to treatment plans and goals;
D. Requesting each change in the level of hospice service including discharge from hospice.

Background
Most hospice services are provided at home⁴ by a licensed certified hospice provider under the direction of an attending physician, who may be the member/enrollee’s primary care physician or the hospice medical director. Hospice services are provided under a plan of care designed by the multidisciplinary team to meet the needs of members/enrollees who are terminally ill, as well as their families.

Hospice services include skilled nursing, homemaker and home health aide services, physician services, physical, occupational and speech therapy, medical social services, volunteer services, nutritional, spiritual, psychosocial/supportive and bereavement counseling related to the management of the terminal illness. Hospice includes drugs and biologics related to the management of the terminal illness, to relieve pain, provide hydration and to deliver enterals as a primary source of nutrition. Durable medical equipment and medical supplies are also included in hospice, when related to the management of a terminal illness.

Appendices

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Appendix A: Palliative Performance Scale (PPS)

Appendix B: Karnofsky Performance Status Scale (KPS) Definitions Rating (%) Criteria

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Appendix C: Functional Assessment Staging Test (FAST) for Alzheimer’s disease

Coding Implications
The following codes are for informational purposes only. They are current at time of review of this policy. Inclusion or exclusion of any codes does not guarantee coverage. Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

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CLINICAL POLICY Hospice Services

References

1. American Cancer Society. Hospice care. https://www.cancer.org/cancer/end-of-life-care/hospice-care.html?sitearea=ETO. Accessed May 20, 2025.

2. Compilation of Patient Protection and Affordable Care Act 2010. Accessed May 20, 2025. https://www.gpo.gov/fdsys/pkg/CPR T-111HPRT61643/pdf/CPR T-111HPRT61643.pdf

3. Medicare Benefit Policy Manual, Chapter 9-Coverage of Hospice Services Under Hospital Insurance, (Rev. 12696 6-25-24) Accessed May 20, 2025. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c09.pdf
4. National Hospice and Palliative Care Organization, Facts and Figures 2024 Edition. Published September, 2024. Accessed May 23, 2025.
5. Palliative Performance Scale (PPS). Version 2. VNS Health. Accessed May 27, 2025. https://www.vnshealth.org/for-professionals/patient-referrals/referring-to-hospice-care/palliative-performance-scale-pps/#:~:text=The%20PPS%20is%20a%20validated,score%20of%20less%20than%202070%25.
6. Karnofsky Performance Status Scale Definitions Rating (%) Criteria. Accessed May 27, 2025. https://emedicine.medscape.com/article/2172510-overview#~:text=The%20Karnofsky%20Performance%20Scale%20Index,worse%20the%2Olikelihood%20of%20survival.
7. End-Stage Indicators. Montgomery Hospice. Accessed May 27, 2025. http://www.montgomeryhospice.org/health-professionals/end-stage-indicators/end-stage-indicators.
8. Local coverage determination: Hospice Determining Terminal Status (L34538). Centers for Medicare and Medicaid Services. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=34538&ver=15&bc=0. Published October 1, 2015 (revised July 11, 2024). Accessed May 27, 2025.
9. Medicare Claims Processing Manual. Chapter 11 – Processing Hospice Claims. (Rev. 12847, 09-13-24). Accessed May 27, 2025.
10. Meier DE, McCormick E, Lagman RL. Hospice: Philosophy of care and appropriate utilization in the United States. UpToDate. www.uptodate.com. Published September 14, 2023. Accessed May 27, 2025.
11. Local coverage determination: Hospice - determining terminal status (L33393). Centers for Medicare and Medicaid Services. http://www.cms.hhs.gov/mcd/search.asp. Published October 1, 2015 (revised November 14, 2019). Accessed May 27, 2025.