HOSPICE PULMONARY DISEASE
[Revised 04/02/1998]
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. 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:
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 (1 and 2 must be present; Documentation of 3, 4, and/or 5 will lend supporting documentation):
1. Severe chronic lung disease as documented by both a and b:
a. disabling dyspnea at rest, poorly or unresponsive 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 predicated is objective evidence for disabling dyspnea, but is not necessary to obtain).
b. progression of end stage pulmonary disease, as evidenced by prior increasing visits to the emergency department or prior hospitalizations for pulmonary infections and/or respiratory failure (documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain).
2. Hypoxemia at rest on room air, as evidenced by p02 ?55 mmHg or oxygen saturation ?88% (these values may be obtained from recent hospital records) or hypercapnia, as evidenced by pCO2 ?50 mmHg (this value may be obtained from recent hospital records).
3. Cor pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left heart disease or valvulopathy).
4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.
5. Resting tachycardia >100/min.
