HOSPICE HEART DISEASE
[Revised #1, 05/21/1998; Revised #2, 12/09/2001]
LMRP DESCRIPTION:
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 intermediary 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. Skillful palliation in patients with end stage heart disease, including judicious use of diuretics and vasodilators, particularly angiotensin-converting enzyme (ACE) inhibitors, may promote survival for long periods with extremely severe symptoms. Conversely, some patients with advanced coronary disease may die suddenly and unexpectedly from acute ventricular arrhythmias. 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.
INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:
The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Medical criteria 1 and 2 are important indications of the severity of heart disease and would thus support a terminal prognosis if met:
1. At the time of initial certification or re-certification for hospice
* Patient is already optimally treated with diuretics and vasodilators, which may include
angiotensin-converting enzymes (ACE) inhibitors or the combination of hydralazine and nitrates. If side effects, such as hypotension or hyerkalemia, prohibit the use of ACE inhibitors or the combination of hydralazine and nitrates, this must be documented in the medical records OR
* Patients having angina pectoris, at rest, resistant to standard nitrate therapy and are either not candidates or decline invasive procedures.
2. The patient has significant symptoms of recurrent congestive heart failure (CHF) at rest, and is classified as a New York Heart Association (NYHA) Class IV:
* Unable to carry on any physical activity without symptoms
* Symptoms are present even at rest
* If any physical activity is undertaken, symptoms are increased
3. Documentation of the following factors may provide additional support for end stage heart disease:
* Treatment resistant symptomatic supraventricular or ventricular arrhythmias
* History of cardiac arrest or resuscitation
* History of unexplained syncope
* Brain embolism of cardiac origin
* Concomitant HIV disease
* Documentation of ejection fraction of 20% or less
