Ala. Admin. Code r. 560-X-51-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-51-.04 - Recipient Eligibility

In order to be eligible to elect hospice care under Medicaid, an individual must be:

(1) Medicaid eligible for full benefits.

(2) Certified by a physician as terminally ill and require hospice services which are medically necessary for the palliation or are medically necessary for symptom and pain management related to the terminal illness. Certification of terminal illness must include specific clinical findings and other medical documentation including, but not limited to, medical records, lab x-rays, pathology reports, etc.

The hospice has the responsibility to establish and maintain a permanent medical record for each patient that includes the following:

(a) Physician certifications

(b) Services provided

(c) Recipient election statement(s)

(d) Interdisciplinary treatment plan of care and updates

(e) Advance directive documentation The documentation contained in the medical record must be a chronological, complete record of the care provided to the hospice recipient. The medical record must contain the Medicaid Hospice Election and Physician's Certification, Form 165 that is signed and dated by the physician. A Form 165 must be present for each election period. Form 165, which was signed by the recipient at the time of certification, may be signed by the physician for recertification for each election period. The documentation must contain the physicians' orders that include medication(s) taken by the recipient, an assessment and a plan of care developed prior to providing care by the attending physician, the medical director or physician designee, and the interdisciplinary team. Identification of a specific terminal illness must be documented and substantiated by labs, x-rays and other medical documentation supporting the terminal illness as set forth by the Medicaid guidelines.

Failure to establish the hospice medical record as defined above shall result in a denial.

The hospice must retain medical records for at least three years after the current year.

Recipients residing in nursing facilities that elect the hospice benefit, but are subsequently determined to be ineligible for hospice care by Medicare or Medicaid, are not automatically approved for Medicaid reimbursement for nursing facility care if hospice payments are denied or recouped. Election of hospice care forfeits other Medicaid benefits.

Recipients who are denied hospice benefits in the nursing facility who intend to remain in the facility must apply and meet the nursing facility level of care criteria and the financial criteria for nursing home coverage by Medicaid.

After the initial certification has been approved, if the diagnosis changes, the recipient will be required to meet the initial criteria for the new diagnosis at the time of the six month recertification.

A person who reaches a point of stability and is no longer considered terminally ill must not be recertified for hospice services. The individual must be discharged to traditional Medicaid benefits. Individuals seeking aggressive treatment shall not be certified for hospice services. "Aggressive treatment" means treatment that is intended to be life-prolonging or curative (rather than palliative) and would prevent the natural course of the terminal illness upon which they are seeking hospice services. Medicaid eligibility for the Hospice program, for recipients who are not dually eligible for Medicare, is based upon financial and medical criteria. The following medical criteria must be present for the terminal illnesses listed below. For diagnoses not found in the Alabama Medicaid Agency administrative code, for cases with evidence of other co-morbidities and the evidence of rapid decline, and for pediatric cases medical necessity review will be conducted on a case-by-case basis.

(a)Hospice Criteria for Adult Failure to Thrive Syndrome

1. Terminal Illness Description: The adult failure to thrive syndrome is characterized by unexplained weight loss, malnutrition and disability. The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes two defining clinical elements, namely nutritional impairment and disability. The nutritional impairment and disability associated with the adult failure to thrive syndrome must be severe enough to impact the patient's short-term survival. The adult failure to thrive syndrome presents as an irreversible progression in the patient's nutritional impairment/disability despite therapy (i.e., treatment intended to affect the primary condition responsible for the patient's clinical presentation).

2. Criteria for initial certification or recertification: Criteria below must be present at the time of initial certification or re-certification for hospice. An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is six months or less if the terminal illness runs its normal course. Patients must meet (i) and (ii) below:

(i) The nutritional impairment associated with the adult failure to thrive syndrome must be severe enough to impact a beneficiary's weight. The Body Mass Index (BMI) of beneficiaries electing the Medicaid Hospice Benefit for the adult failure to thrive syndrome must be below 22 kg/m ² and the patient must be either declining enteral/parenteral nutritional support or has not responded to such nutritional support.

(ii) The disability associated with the adult failure to thrive syndrome should be such that the individual is significantly disabled. Significant disability must be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%.

Both the recipient's BMI and level of disability should be determined using measurements/observations made within six months (180 days) of the most recent certification/recertification date. If enteral nutritional support has been instituted prior to the hospice election and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification. At the time of recertification recumbent measurement(s) - (anthropometry) such as mid-arm circumference in cm may be substituted for BMI with documentation as to why a BMI could not be measured. This information will be subject to review on a case by case basis.

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits.

(b)Hospice Criteria for Adult HIV Disease

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

HIV Disease (i) and (ii) must be present; factors from (iii) will add supporting documentation)

(i) CD4+ Count less than 25 cells/mcL or persistent viral load greater than 100,000 copies/ml, plus one of the following:

(I) CNS lymphoma

(II) Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)

(III) Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused

(IV) Progressive multifocal leukoencephalopathy

(V) Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy

(VI) Visceral Kaposi's sarcoma unresponsive to therapy

(VII) Renal failure in the absence of dialysis

(VIII) Cryptosporidium infection

(IX) Toxoplasmosis, unresponsive to therapy

(ii) Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of less than or equal to 50

(iii) Documentation of the following factors will support eligibility for hospice care:

(I) Chronic persistent diarrhea for one year

(II) Persistent serum albumin less than 2.5 gm/dl

(III) Age greater than 50 years

(IV) Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

(V) Advanced AIDS dementia complex

(VI) Toxoplasmosis

(VII) Congestive heart failure, symptomatic at rest, New York Heart Association (NYHA) classification Stage IV

3. Criteria for recertification: Criteria below must be present at the time of recertification for hospice. Both (i) and (ii) must be met. Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet one of the conditions in (i) and meet the requirement in (ii):

(i) Persistent viral load greater than 100,000 copies/ml, plus one of the following:

(I) CNS lymphoma

(II) Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)

(III) Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused

(IV) Progressive multifocal leukoencephalopathy

(V) Systemic lymphoma, unresponsive or partially responsive to chemotherapy

(VI) Visceral Kaposi's sarcoma unresponsive to therapy

(VII) Renal failure in the absence of dialysis

(VIII) Cryptosporidium infection

(IX) Toxoplasmosis, unresponsive to therapy

(ii) Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, of less than or equal to 50

(iii) Documentation of the following factors will support eligibility for hospice care:

(I) Chronic persistent diarrhea for one year

(II) Persistent serum albumin less than 2.5 gm/dl

(III) Age greater than 50 years

(IV) Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

(V) Advanced AIDS dementia complex

(VI) Toxoplasmosis

(VII) Congestive heart failure, symptomatic at rest, New York Heart Association (NYHA) classification Stage IV

4. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy

(ii) Absence of supporting documentation of progression or rapid decline

(iii) Failure to document terminal status of six months or less.

(iv) Patient on antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease.

(v) Patient is not eligible for full Medicaid benefits.

(c)Hospice Criteria for Adult Pulmonary Disease

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

2. Criteria for initial certification: Criteria below must be present at the time of initial certification for hospice. Patients will be considered to be in the terminal stage of pulmonary disease (life expectancy of six months or less) if they meet the following criteria. The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease: (i) and (ii) must be present; documentation of (iii), (iv) and/or (v) will lend supporting documentation:

(i) Severe chronic lung disease as documented by both factors below:

(I) Patient with Forced Expiratory Volume in one second [FEV1], after bronchodilator, less than 30% of predicted and disabling dyspnea at rest, poorly responsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough (documentation of Forced Expiratory Volume in one second [FEV1], after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea and must be provided when performed). If the FEV1 has not been performed, the clinical condition must support an FEV1 less than 30% of predicted.

(II) Progression of end stage pulmonary disease as documented by two or more episodes of pneumonia or respiratory failure requiring ventilatory support within the last six months. Alternatively, medical record documentation of serial decrease in FEV1 greater than 40 ml/year for the past two years can be used to demonstrate progression.

(ii) Hypoxemia at rest on room air, with a current ABG PO2 at or below 59 mm Hg or oxygen saturation at or below 89% taken at rest or hypercapnia, as evidenced by PCO2 greater than or equal to 50 mmHg (these values may be obtained from recent hospital records).

(iii) Cor pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g. not secondary to left heard disease or valvulopathy).

(iv) Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.

(v) Resting tachycardia greater than 100/min.

3. Criteria for recertification: Criteria below must be present at the time of recertification for hospice. Patients will be considered to be in the terminal stage of their illness (life expectancy of six months or less) if they meet (i) and (ii) below:

(i) Severe disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough.

(ii) Hypoxemia at rest on room air, with a current ABG PO2 at or below 59 mm Hg or oxygen saturation at or below 89% taken at rest or hypercapnia as evidenced by PCO2 greater than or equal to 50 mm Hg.

4. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is on non-emergent, artificial ventilator support,

(v) Patient is not eligible for full Medicaid benefits.

(d)Hospice Criteria for Adult Alzheimer's Disease &Related Disorders

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less. Alzheimer's disease and related disorders are further substantiated with medical documentation of a progressive decline in the Reisburg Functional Assessment Staging (FAST) Scale, within a six-month period of time, prior to the Medicaid hospice election.

2. Criteria below must be present at the time of initial certification and recertification for hospice. Alzheimer's disease and related disorders may support a prognosis of six months or less under many clinical scenarios. The structural and functional impairments associated with a primary diagnosis of Alzheimer's disease are often complicated by co morbid and/or secondary conditions. Co-morbid conditions affecting beneficiaries with Alzheimer's disease are by definition distinct from the Alzheimer's disease itself-examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions on the other hand are directly related to a primary condition - in the case of Alzheimer's disease examples include delirium and pressure ulcers. The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer's disease and a prognosis of six months or less. The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer's disease. Stage 7 identifies the threshold of activity limitation that would support a six-month prognosis; however at least 4 of the 6-substage FAST scale indicators must be present. The FAST Scale does not address the impact of co-morbid or secondary conditions. The presence of secondary conditions is thus considered separately by this policy. Patients must beet (i) and (ii) below:

(i) To be eligible for hospice, the individual must have documentation of a FAST scale level equal to 7 and documentation of at least 4 or 6 substage FAST scale indicators under level 7.

FAST Scale Items:

Stage #1: No difficulty, either subjectively or objectively Stage #2: Complains of forgetting location of objects; subjective work difficulties Stage #3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations Stage #4: Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances)

Stage #5: Requires assistance in choosing proper clothing Stage #6: Decreased ability to dress, bathe, and toilet independently:

Sub-stage 6a: Difficulty putting clothing on properly Sub-stage 6b: Unable to bathe properly; may develop fear of bathing Sub-stage 6c: Inability to handle mechanics of toileting (e.g., forgets to flush the toilet, does not wipe properly)

Sub-stage 6d: Urinary incontinence Sub-stage 6e: Fecal incontinence Stage #7: Loss of speech, locomotion, and consciousness:

Sub-stage 7a: Ability to speak limited to approximately a half dozen intelligible different words or fewer, in the course of an average day or in the course of an intensive interview Sub-stage 7b: All intelligible vocabulary lost (Speech ability limited to the use of a single intelligible word in an average day or in the course of an intensive interview - the person may repeat the word over and over)

Sub-stage 7c: Non-ambulatory (Ambulatory ability lost - cannot walk without personal assistance)

Sub-stage 7d: Unable to sit up independently (Cannot sit up without assistance - e.g., the individual will fall over if there are not lateral rests [arms] on the chair)

Sub-stage 7e: Loss of ability to smile Sub-stage 7f: Loss of ability to hold head up independently

(ii) Documentation of specific secondary condition(s) related to Alzheimer's Disease must be present, including but not limited to, Contractures, Pressure Ulcers, recurrent UTI, Dysphagia, Aspiration Pneumonia.

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits.

(e)Hospice Criteria for Adult Stroke and/or Coma

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

2. Criteria below must be present at the time of initial certification and recertification for hospice. The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of stroke. Patients must meet (i) and (ii) below:

(i) A Palliative Performance Scale (PPS) of less than or equal to 40.

(I) Degree of ambulation-Mainly in bed

(II) Activity/extent of disease-not able to do work; extensive disease

(III) Ability to do self-care -Mainly Assistance

(IV) Food/fluid intake-Normal to reduced

(V) State of consciousness -Either fully conscious or drowsy/confused

(ii) Inability to maintain hydration and caloric intake with any one of the following:

(I) Weight loss greater than 10% during previous 3 months

(II) Weight loss greater than 7.5% in previous 6 weeks

(III) Serum albumin less than 2.5 gm/dl

(IV) Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events.

(V) Calorie counts documenting inadequate caloric/fluid intake. (Patient's height and weight-caloric intake is too low to maintain normal BMI or fewer calories than necessary to maintain normal BMI - determine with caloric counts)

(VI) Dysphagia severe enough to prevent the patient from receiving food and fluids necessary to sustain life in a patient who declines or does not receive artificial nutrition and hydration.

(iii) The medical criteria for 3 listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology):

(I) Comatose patients with any 3 of the following on day three or after of coma:

I. abnormal brain stem response

II. absent verbal response

III. absent withdrawal response to pain

IV. increase in serum creatinine greater than 1.5 mg/dl

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits

(f)Hospice Criteria for Adult Amyotrophic Lateral Sclerosis (ALS)

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

2. Criteria for initial certification: Criteria below must be present at the time of initial certification for hospice. ALS tends to progress in a linear fashion over time. The overall rate of decline in each patient is fairly constant and predictable, unlike many other non-cancer diseases. No single variable deteriorates at a uniform rate in all patients. Therefore, multiple clinical parameters are required to judge the progression of ALS. Although ALS usually presents in a localized anatomical area, the location of initial presentation does not correlate with survival time. By the time patients become end-stage, muscle denervation has become widespread, affecting all areas of the body, and initial predominance patterns do not persist. In end-stage ALS, two factors are critical in determining prognosis: ability to breathe, and to a lesser extent ability to swallow. The former can be managed by artificial ventilation, and the latter by gastrostomy or other artificial feeding, unless the patient has recurrent aspiration pneumonia. While not necessarily a contraindication to hospice care, the decision to institute either artificial ventilation or artificial feeding will significantly alter six-month prognosis. Examination by a neurologist within three months of assessment for hospice is required, both to confirm the diagnosis and to assist with prognosis. Patients will be considered to be in the terminal stage of ALS (life expectancy of six months or less) if they meet the following criteria (must fulfill i, ii,oriii):

(i) The patient must demonstrate critically impaired breathing capacity

(I) Critically impaired breathing capacity as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:

I. Vital capacity (VC) less than 30% of normal

II. Continuous dyspnea at rest

III. Hypoxemia at rest on room air, with a current ABG PO2 at or below 59mm HG or oxygen saturation at or below 89%

IV. Patient declines artificial ventilation

(ii) Patient must demonstrate both rapid progression of ALS and critical nutritional impairment

(I) Rapid progression of ALS as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:

I. Progression from independent ambulation to wheelchair or bed bound status

II. Progression from normal to barely intelligible or unintelligible speech

III. Progression from normal to pureed diet

IV. Progression from independence in most or all activities of daily living (ADLs) to needing major assistance by caretaker in all ADLs.

(II) Critical nutritional impairment as demonstrated by all the following characteristics occurring within the 12 months preceding initial hospice certification:

I. Oral intake of nutrients and fluids insufficient to sustain life

II. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.

(iii) Patient must demonstrate both rapid progression of ALS and life-threatening complications

(I) Rapid progression of ALS, see (ii) (I) above

(II) Life-threatening complications as demonstrated by one of the following characteristics occurring within the 12 months preceding initial hospice certification:

I. Two or more episodes of recurrent aspiration pneumonia (with or without tube feedings)

II. Upper urinary tract infection (pyelonephritis) Sepsis

III. Other medical complications not identified above will be reviewed on a case-by-case basis with appropriate medical justification

(i) The patient must demonstrate critically impaired breathing capacity

(I) Critically impaired breathing capacity as demonstrated by all the following characteristics:

I. Continuous dyspnea at rest

II. Hypoxemia at rest on room air with a current ABG PO2 at or below 59 mm Hg or oxygen saturation at or below 89%

III. Patient declines artificial ventilation

(ii) Patient must demonstrate rapid progression of ALS and at least one life-threatening complication.

(I) Life-threatening complications as demonstrated by one of the following characteristics:

I. Two or more episodes of recurrent aspiration pneumonia (with or without tube feedings)

II. Upper urinary tract infection (pyelonephritis) Sepsis

III. Other medical complications not identified above will be reviewed on a case-by-case basis with appropriate medical justification

4. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits

(g)Hospice Criteria for Adult Cancer

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

2. Criteria for initial certification or recertification: Criteria below must be present at the time of initial certification or re-certification for hospice. Patients will be considered to be in the terminal stage of cancer (life expectancy of six months or less) if (i) or (ii) below are present:

(i) Documentation of metastasis or final disease stage is required with evidence of progression as documented by worsening clinical status, symptoms, signs and/or laboratory results.

(ii) Progression from an earlier stage of disease to metastatic disease with either:

(I) A continued decline in spite of therapy, that is, aggressive treatment, or

(II) Patient declines further disease directed therapy.

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits

(h)Hospice Criteria for Adult Heart Disease

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

2. Criteria for initial certification or recertification: Criteria below must be present at the time of initial certification or re-certification for hospice. The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Medical criteria (i) and (ii) must be present as they are important indications of the severity of heart disease and would thus support a terminal prognosis if met.

(i) When the patient is approved or recertified, the patient must already be optimally treated with Beta Blockers, diuretics, and vasodilators, which may include AngiotensinConverting Enzymes (ACE) inhibitors or Angiotensin Receptive Blockers (ARBs) for a diagnosis of Heart Failure. This paragraph does not need to be satisfied if any of the following conditions are documented in the medical record and present at the time of certification or recertification:

(I) Side effects, such as hypotension or hyperkalemia; or

(II) Evidence of treatment failure of ACE inhibitors, ARBs, or a combination of hydralazine and nitrates; or

(III) The patient voluntarily declines treatment.

(ii) The patient has significant symptoms of recurrent heart failure at rest, and is classified as a New York Heart Association (NYHA) Class IV:

(I) Unable to carry on any physical activity without symptoms

(II) Symptoms are present even at rest

(III) If any physical activity is undertaken, symptoms are increased

(iii) Documentation of the following factors may provide additional support for end stage heart disease:

(I) Treatment resistant symptomatic supraventricular or ventricular arrhythmias

(II) History of cardiac arrest or resuscitation

(III) History of unexplained syncope

(IV) Brain embolism of cardiac origin

(V) Concomitant HIV disease

(VI) Documentation of ejection fraction of 20% or less

(VII) Angina pectoris, at rest

(iv) The use of IV Milrinone or Dobutamine does not limit initial certification or recertification of hospice if it is considered palliative and is not likely to change the terminal prognosis of the patient.

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits

(i)Hospice Criteria for Adult Liver Disease

1. Terminal Illness Description: 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.

2. Criteria for initial certification and recertification: Criteria below must be present at the time of initial certification/recertification for hospice. 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. Documentation in the record must support both (i) and (ii).

(i) Documentation of progression with active decline as evidenced by worsening clinical status, symptoms, signs and laboratory results. The patient's terminal condition must be supported by one or more of the items below:

(I) Clinical Status

I. Recurrent or intractable infections such as pneumonia, sepsis or upper urinary tract.

II. Documented progressive inanition.

(II) Symptoms

I. Dyspnea with increasing respiratory rate

II. Nausea/vomiting poorly responsive to treatment

III. Diarrhea, intractable

IV. Pain requiring increasing doses of major analgesics more than briefly.

(III) Signs

I. Ascites

II. Edema

III. Weakness

IV. Change in level of consciousness

(IV) Laboratory (When available. Lab testing is not required to establish hospice eligibility.)

I. Increasing pCO2 or decreasing pO2 or decreasing SaO2

II. Increasing liver function studies

III. Progressively decreasing or increasing serum sodium

(V) Decline in Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) due to progression of disease.

(VI) Progression to dependence on assistance with additional activities of daily living.

(VII) History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit.

(ii) End stage liver disease is present and the patient shows at least one of the following:

(I) ascites, refractory to treatment or patient non-complaint

(II) spontaneous bacterial peritonitis

(III) hepatorenal syndrome (elevated serum creatinine and BUN with oliguria (< 400ml/day) and urine sodium concentration less than10 mEq/l

(IV) hepatic encephalopathy, refractory to treatment, or patient non-compliant

(V) recurrent variceal bleeding, despite intensive therapy

(iii) Documentation of the following factors will also support eligibility for hospice care:

(I) progressive malnutrition

(II) muscle wasting with reduced strength and endurance

(III) continued active alcoholism (>80 gm ethanol/day)

(IV) hepatocellular carcinoma

(V) HBsAg (Hepatitis B) positivity

(VI) Hepatitis C refractory to interferon treatment

3. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is not eligible for full Medicaid benefits

(j)Hospice Criteria for Adult Renal Disease

1. Terminal Illness Description: An individual is considered to be terminally ill if the medical prognosis indicates a life expectancy of six months or less.

(i)Acute renal failure (I) and (II) must be present)

(I) Creatinine clearance less than 10 cc/min (less than 15 cc/min. for diabetes)

(II) Serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes)

(ii)Chronic renal failure (I), (II), and (III) must be present)

(I) Creatinine clearance less than 10 cc/min (less than 15cc/min for diabetes)

(II) Serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes)

(III) Glomerular filtration rate (GFR) less than 30 ml/min

(i)Chronic renal failure (I), (II), or (III) must be present)

(I) Creatinine clearance less than 10 cc/min (less than 15cc/min for diabetes)

(II) Serum creatinine greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetes)

(III) Glomerular filtration rate (GFR) less than 30 ml/min

4. Reasons for Denial

(i) Patients not meeting the specific medical criteria in this policy.

(ii) Absence of supporting documentation of progression or rapid decline.

(iii) Failure to document terminal status of six months or less.

(iv) Patient is on dialysis.

(iv) Patient is not eligible for full Medicaid benefits

Ala. Admin. Code r. 560-X-51-.04

Emergency Rule effective October 1, 1990. Permanent Rule effective February 13, 1991. Amended: Filed May 16, 2001; effective June 20, 2001. Amended: Filed May 12, 2005; effective June 16, 2005. Amended: Filed April 11, 2006; effective May 16, 2006. Amended: Filed September 12, 2006; effective October 17, 2006. Amended: Filed May 11, 2011; effective June 15, 2011. Amended: Filed August 15, 2011; effective September 19, 2011. Amended: Filed August 9, 2012; effective September 13, 2012.

Amended by Alabama Administrative Monthly Volume XXXIII, Issue No. 06, March 31, 2015, eff. 4/20/2015.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 10, July 30, 2021, eff. 9/13/2021.

Author: Robin Arrington, Administrator, LTC Provider/Recipient Services Unit, Long Term Care Division

Statutory Authority: Title XIX, Social Security Act; 42 C.F.R. § 418.20; State Plan.