STROKE & COMA
HOSPICE STROKE AND/OR COMA
[Revised 08/1/01]
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, Palmetto GBA has established a 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:
The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of stroke. Medical criteria 1 and 2 are important indicators of functional and nutritional status respectively, and would thus support a terminal prognosis if met.
A Palliative Performance Scale (PPS) of £ 40.
a. Degree of ambulation
• Mainly in bed
b. Activity/extent of disease
• Unable to do work; extensive disease
c. Ability to do self-care
• Mainly Assistance
d. Food/fluid intake
• Normal to reduced
e. State of consciousness
• Either fully conscious or drowsy/confused
1. Inability to maintain hydration and caloric intake with one of the following:
a. Weight loss > 10% during previous 6 months
b. Weight loss > 7.5% in previous 3 months
c. Serum albumin < 2.5 gm/dl
d. Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events.
e. Calorie counts documenting inadequate caloric/fluid intake.
If a beneficiary does not meet both medical criteria #1 and #2 the documentation should describe a relevant comorbidity and/or rapid decline.
The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology):
Comatose patients with any 3 of the following on day three of coma:
a. abnormal brain stem response
b. absent verbal response
c. absent withdrawal response to pain
d. serum creatinine >1.5 mg/dl
