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 6 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 Medicare Administrative Contractor (MAC) 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 their illness (life expectancy of 6 months or less) if they meet the following criteria:

 Human Immunodeficiency Virus (HIV) Disease (1 and 2 must be present; factors from 3 will add supporting documentation)

 1. Clusters of differentiation 4 (CD4)+ Count 100,000 copies/ml, plus 1 of the following:

a. Central Nervous System (CNS) lymphoma
b. Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)
c. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
d. Progressive multifocal leukoencephalopathy
e. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
f. Visceral Kaposi's sarcoma unresponsive to therapy
g. Renal failure in the absence of dialysis
h. Cryptosporidium infection
i. Toxoplasmosis, unresponsive to therapy

 2. Decreased performance status as measured by the Karnofsky Performance Status (KPS) scale, of ≤ 50.

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

a. Chronic persistent diarrhea for 1 year
b. Persistent serum albumin <2.5
c. Concomitant, active substance abuse
d. Age > 50 years
e. Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
f. Advanced acquired immunodeficiency syndrome (AIDS) dementia complex
g. Toxoplasmosis
h. Congestive heart failure (CHF), symptomatic at rest