Summary Of Evidence

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Analysis of Evidence

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Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this A/B Medicare Administrative Contractor (MAC)(HHH) has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research, and may be revised as more research is available. Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.

Patients will be considered to be in the terminal stage of liver disease (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 must be present; factors from 3 will lend supporting documentation):

1. The patient should show both a and b:

a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5

        b. Serum albumin <2.5 gm/dl

 2. End stage liver disease is present and the patient shows at least one of the following:

       a. Ascites, refractory to treatment or patient non-compliance

       b. Spontaneous bacterial peritonitis

       c. Hepatorenal syndrome (elevated creatinine and blood urea nitrogen (BUN) with oliguria (<400 ml/day) urine and sodium concentration <10 mEq/l)

       d. Hepatic encephalopathy, refractory to treatment, or patient non-compliance

       e. Recurrent variceal bleeding, despite intensive therapy

 3. Documentation of the following factors will support eligibility for hospice care:

       a. Progressive malnutrition

       b. Muscle wasting with reduced strength and endurance

       c. Continued active alcoholism (> 80 gm ethanol/day)

       d. Hepatocellular carcinoma

       e. Hepatitis B virus surface antigen (HBsAg)positivity

       f. 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 must be discharged from hospice.