National Medical Policy

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1 National Medical Policy Subject: Policy Number: Hospice Care NMP238 Effective Date*: September 2005 Updated: September 2007, January 2011 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website National Coverage Decision (NCD) CMS Benefit Manual X Local Coverage Decision (LCD) Hospice - Determining Terminal Status: ch Article (Local) Other None Use Health Net Policy Instructions Medicare NCDs and Benefit Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website, then enter the topic and your specific state to find the coverage instructions for your region If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or Benefit Manual If there is no NCD, Benefit Manual or LCD specific to your region, please use Health Net National Medical Policy Current Policy Statement: Hospice Care Jan 11 1

2 1. General Criteria for Admission into Hospice Program The physician certifies that the patient has an established diagnosis, whether from a malignant or non-malignant cause, with a life expectancy of six months or less if the terminal illness runs its normal course*; and Patient needs palliative treatment ("comfort care"), not curative treatment, i.e., aggressive work-up, treatment and hospitalizations is medically futile; and The services must be provided according to a doctor-prescribed treatment plan; and All hospice services must be performed by appropriately qualified/licensed personnel; and Continuity of care must be assured for the patient and family regardless of setting (home, outpatient, or inpatient); and Hospice care is available 24 hours a day, seven days a week. Note: Although hospice criteria allows for patients to be admitted with a six-month prognosis, too often patients are referred in the last weeks of their lives. The earlier a patient is admitted to the program, the greater the benefit to the patient and family. 2. Description A hospice care program consists of, but is not limited to, the following: Professional services of a registered nurse, licensed practical nurse, or licensed vocational nurse; Physical therapy, occupational therapy, and speech therapy; Medical and surgical supplies and durable medical equipment; Prescribed drugs; In-home laboratory services; Medical social service consultations; Inpatient hospice room, board, and general nursing service; Inpatient respite care, which is short-term care provided to the patient only when necessary to relieve the family member or other persons caring for the individual; Family counseling related to the patient s terminal condition; Dietitian services; Pastoral services Bereavement services; Educational services; Home health aide services consisting primarily of a medical or therapeutic nature and furnished to a patient who is receiving appropriate nursing or therapy services. 3. Levels of Care There are four levels of care provided by a licensed hospice program: Hospice Care Jan 11 2

3 Routine home care is home care provided by the hospice program when the patient is not receiving one of the other levels of care. Fewer than 8 hours of care during a 24 hour period is necessary. Continuous home care is care provided in the home during a period of crisis necessary to maintain the patient in the home setting. The patient requires mainly nursing care to achieve relief of acute medical symptoms. A minimum of 8 hours of care during a 24 hour period must be necessary to qualify for this level of care. Inpatient respite care is when the patient s condition requires the support of an inpatient hospice facility for no greater than 5 days to adjust medication which cannot be performed in another setting, stabilization of treatment, or provide relief to the regular family caregivers. Respite care may only be eligible for coverage as part of the hospice benefit or through Case Management (check certificate for eligible benefits) General inpatient care is when the patient is admitted to a hospice unit for round-the-clock care. Home Care Visits Health Net, Inc. considers visits by all skilled services (i.e., skilled nursing and/or home health aide services, physical, occupational and speech therapies, medical social services and nutritional services) medically necessary for not more than four (4) hours in aggregate per day. Inpatient Hospice Care We consider acute inpatient hospice care** medically necessary when any of the following is met: 1. Patient requires short-term inpatient palliative hospice care consisting of discomfort evaluation and development of a program aimed at the reduction or abatement of pain and symptoms (physical, sociological, spiritual, emotional or psychological) which will make it possible for the patient to enjoy quality of life after returning to the home setting in a few days. 2. Family members are unable to provide care or cope with the patient at home, or when an illness results in problems which are difficult to deal with at home 3. The patient requires skilled and professional acute or intensive care as the illness progresses 4. Patient is admitted for short-term management of pain or symptoms to give family members relief for a brief period of time (known as respite care) ** Note Inpatient hospice presumes a plan of care that is primarily focused on symptom control and not on diagnostic work-up or aggressive therapy of the underlying disease. Discharge criteria: 1. Patient's condition improves and the disease goes into remission such that patient can return home and go about their daily life Hospice Care Jan 11 3

4 2. Patient requires a return to aggressive therapy such that cessation of efforts to medically treat the patient no longer applies Note: We consider only up to twelve (12) days in the six-month period medically appropriate. Respite Care We consider respite care only for a maximum of five (5) consecutive days with a maximum of fourteen (14) days per calendar year medically necessary. We consider any of the following investigational and therefore not medically necessary: Medical care rendered by a doctor; Homemaker services such as cooking and housekeeping, food or meals, or private duty nursing services. Services provided to other than the terminally ill Insured, including bereavement counseling for family members. Pastoral and spiritual counseling. Services performed by family members or volunteer workers. Homemaker or housekeeping services, except by home health aides, as ordered in the hospice treatment plan. Supportive environmental materials, including but not limited to handrails, ramps, Air conditioners, and telephones. Normal necessities of living, including but not limited to food, clothing and household supplies. Food service, such as "Meals on Wheels." Separate charges for reports, records, or transportation. Legal and financial counseling services. Services and supplies not included in the hospice treatment plan or not specifically set forth as a hospice benefit. Services and supplies in excess of the stated limitations or services and supplies provided more than six (6) months after the initial date of covered hospice care A patient will be considered to have a life expectancy of six months or less if he/she meets the non-disease specific "Decline in clinical status" guidelines described below. Alternatively, the baseline non-disease specific guidelines described in section II plus the applicable disease specific guidelines listed in section III will establish the necessary expectancy. Hospice Care Jan 11 4

5 Some patients may not meet these guidelines, yet still have a life expectancy of six months or less. Coverage for these patients may be approved on an individual consideration basis. I. Decline in Clinical Status: Patients will be considered to have a life expectancy of six months or less if there is documented evidence of decline in clinical status such as: 1. Progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Clinical Status: Recurrent or intractable serious infections such as pneumonia, sepsis or pyelonephritis; Progressive inanition as documented by: Weight loss of at least 10% body weight in the prior six months, not due to reversible causes such as depression or use of diuretics; Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth), not due to reversible causes such as depression Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other observation of weight loss in a patient without documented weight; Decreasing serum albumin or cholesterol. Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by decreasing food portion consumption Symptoms: Dyspnea with increasing respiratory rate; Cough, intractable; Nausea/vomiting poorly responsive to treatment; Diarrhea, intractable; Pain requiring increasing doses of major analgesics more than briefly Signs: Decline in systolic blood pressure to below 90 or progressive postural hypotension; Ascites; Hospice Care Jan 11 5

6 Venous, arterial or lymphatic obstruction due to local progression or metastatic disease; Edema; Pleural/pericardial effusion; Weakness; Change in level of consciousness. Laboratory (When available. Lab testing is not required to establish hospice eligibility.): Increasing pco2 or decreasing po2 or decreasing SaO2; Increasing calcium, creatinine or liver function studies; Increasing tumor markers (e.g. CEA, PSA); Progressively decreasing or increasing serum sodium or increasing serum potassium. 2. Decline in Karnofsky Performance Status (KPSz) or Palliative Performance Score (PPS) due to progression of disease. 3. Progressive decline in Functional Assessment Staging (FAST) for dementia (from 7A on the FAST). 4. Progression to dependence on assistance with additional activities of daily living (see Part II, Section 2). 5. Progressive stage 3-4 pressure ulcers in spite of optimal care. 6. History of increasing ER visits, hospitalizations, or physician visits related to the hospice primary diagnosis prior to election of the hospice benefit. II. Non-disease specific baseline guidelines (both A and B should be met) 1. Physiologic impairment of functional status as demonstrated by: Karnofsky Performance Status (KPS) or Palliative Performance Score (PPS) < 70%. Note that two of the disease specific guidelines (HIV Disease, Stroke and Coma) establish a lower qualifying KPS or PPS. 2. Dependence on assistance for two or more activities of daily living (ADLs): Ambulation; Continence; Transfer; Dressing; Feeding; Hospice Care Jan 11 6

7 Bathing. 1. Co-morbidities although not the primary hospice diagnosis, the presence of disease such as the following, the severity of which is likely to contribute to a life expectancy of six months or less, should be considered in determining hospice eligibility. Chronic obstructive pulmonary disease Congestive heart failure Ischemic heart disease Diabetes mellitus Neurologic disease (CVA, ALS, MS, Parkinson s) Renal failure Liver Disease Neoplasia Acquired immune deficiency syndrome Dementia Aquired Immune Deficiency Syndrome/HIV Refractory severe autoimmune disease (e.g. Lupus or Rheumatoid Arthritis) III. Disease specific Guidelines Cancerous Terminal Illnesses 1. Disease with metastases at presentation OR 2. Progression from an earlier stage of disease to metastatic disease with either: A continued decline in spite of therapy; or Patient declines further disease directed therapy. Note: Certain cancers with poor prognoses (e.g., small cell lung cancer, brain cancer and pancreatic cancer) may be hospice eligible without fulfilling the other criteria in this section. Non-Cancerous Terminal Illnesses Recognizing that determination of life expectancy during the course of a noncancerous terminal illness is difficult, medical criteria for determining prognosis based on available scientific research appears to be a reasonable approach for determining prognosis. As such, we do not consider hospice care medically necessary when the medical criteria and guidelines shown below are not met. However, some patients may not meet the criteria, yet still be necessary for hospice care, because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis. End Stage Heart Disease 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. The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Hospice Care Jan 11 7

8 Any of the medical criteria below are important indications of the severity of heart disease and would thus support a terminal stage of heart disease (life expectancy of six months or less) if met: 1. Either 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 hyperkalemia, prohibit the use of ACE inhibitors or the combination of hydralazine and nitrates, this must be documented in the medical records 2. Patient having angina pectoris at rest, resistant to standard nitrate therapy and are either not candidates for invasive revascularization procedures or decline those procedures. 3. 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 Note: 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 End Stage Pulmonary Disease 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 as documented by all of the following: 1. 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). 2. 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 > Hospice Care Jan 11 8

9 40 ml/year is objective evidence for disease progression, but is not necessary to obtain). 3. Hypoxemia at rest on room air, as evidenced by p02 < 55 mm Hg or oxygen saturation < 88% on supplemental oxygen or hypercapnia, as evidenced by pco2 > 50 mm Hg. In addition, any of the following will lend supporting documentation: 1. Cor pulmonale and right heart failure (RHF) secondary to pulmonary disease (e.g., not secondary to left heart disease or valvulopathy). 2. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months. 3. Resting tachycardia >100/min. End Stage Liver Disease 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 (1 and 2 must be present; factors from 3 will lend supporting documentation): 1. The patient must have both of the following: Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR) > 1.5 Serum albumin <2.5 gm/d1 2. End stage liver disease is present and the patient must show at least one of the following: Ascites, refractory to treatment or patient non-complaint Spontaneous bacterial peritonitis Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10 meq/l) Hepatic encephalopathy, refractory to treatment, or patient non-complaint Recurrent variceal bleeding, despite intensive therapy 3. Documentation of the following factors will support eligibility for hospice care: Progressive malnutrition Muscle wasting with reduced strength and endurance Continued active alcoholism (>80 gm ethanol/day) Hepatocellular carcinoma HBsAg (Hepatitis B) positivity Hepatitis C refractory to interferon treatment Note: Patients awaiting liver transplant who otherwise fit the above criteria must be discharged from hospice if a donor organ is procured. Hospice Care Jan 11 9

10 End Stage Acute Renal Failure Patients will be considered to be in the terminal stage of acute renal failure (life expectancy of six months or less), if they meet the following criteria (1 and either 2, 3 or 4 must be present - factors from 5 will lend supporting documentation): 1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis; 2. Creatinine clearance < 10 cc/min (less than 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. 3. Serum creatinine > 8.0 mg/dl (greater than 6.0 mg/dl for diabetics); 4. Estimated glomerular filtration rate (GFR) <10 ml/min. 5. Comorbid conditions: Mechanical ventilation; Malignancy (other organ system); Chronic lung disease; Advanced cardiac disease; Advanced liver disease; Immunosuppression/AIDS; Albumin, less than 3.5 gm/dl; Platelet count, less than 25,000; Disseminated intravascular coagulation; Gastrointestinal bleeding End Stage Chronic Renal Failure Patients will be considered to be in the terminal stage of chronic renal failure (life expectancy of six months or less), if they meet the following criteria (1 and either 2, 3 or 4 must be present - factors from 5 will lend supporting documentation): 1. The patient is not seeking dialysis or renal transplant or is discontinuing dialysis; 2. Creatinine clearance of less than 10 cc/min (less than 15 cc/min for diabetics); or < 15cc/min (< 20cc/min for diabetics) with comorbidity of congestive heart failure. 3. Serum creatinine, greater than 8.0 mg/dl (greater than 6.0 mg/dl for diabetics); 4. Signs and symptoms of renal failure: Uremia; Oliguria (less than 400 cc/day); Intractable hyperkalemia (greater than 7.0), not responsive to treatment; Uremic pericarditis; Hepatorenal syndrome; Intractable fluid overload, not responsive to treatment. Hospice Care Jan 11 10

11 5. Estimated glomerular filtration rate (GFR) <10 ml/min. End-stage Amyotrophic Lateral Sclerosis ALS tends to progress in a linear fashion over time, thus the overall rate of decline in each patient is fairly constant and predictable. Multiple clinical parameters are required to judge the progression of ALS. Progression of disease differs markedly from patient to patient. In end-state ALS, two factors are critical in determining prognosis: ability to breathe, and ability to swallow. Patients are considered eligible for Hospice care if they do not elect tracheostomy and invasive ventilation and display evidence of critically impaired respiratory function (with or without use of NIPPV) and/or severe nutritional insufficiency (with or without use of a gastrostomy tube). 1. Critically impaired respiratory function is as defined by: FVC < 40% predicted (seated or supine) and 2 or more of the following symptoms and/or signs: Dyspnea at rest; Orthopnea; Use of accessory respiratory musculature; Paradoxical abdominal motion; Respiratory rate > 20; Reduced speech / vocal volume; Weakened cough; Symptoms of sleep disordered breathing; Frequent awakening; Daytime somnolence / excessive daytime sleepiness; Unexplained headaches; Unexplained confusion; Unexplained anxiety; Unexplained nausea. Note: If unable to perform the FVC test patients meet this criterion if they manifest 3 or more of the above symptoms/signs. 2. Severe nutritional insufficiency defined as dysphagia with progressive weight loss of at least five percent of body weight with or without election for gastrostomy tube insertion. End Stage Stroke Patients will be considered to be in the terminal stage of stroke (life expectancy of six months or less) if they meet all of the following criteria: 1. Karnofsky Performance Status (KPS) or A Palliative Performance Scale (PPS) of < 40: Hospice Care Jan 11 11

12 Degree of ambulation - mainly in bed Activity/extent of disease - unable to do work; extensive disease Ability to do self-care - mainly assistance Food/fluid intake - normal to reduced State of consciousness - either fully conscious or drowsy/confused 2. Inability to maintain hydration and caloric intake with any of the following: Weight loss > 10% during previous 6 months Weight loss > 7.5% in previous 3 months Serum albumin < 2.5 gm/dl Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events; Sequential calorie counts documenting inadequate caloric/fluid intake; Dysphagia severe enough to prevent patient from continuing fluids/foods necessary to sustain life and patient does not receive artificial nutrition and hydration Note: If a patient does not meet both medical criteria #1 and #2 the documentation should describe a relevant comorbidity and/or rapid decline. End Stage Coma 1. Patients will be considered to be in the terminal stage of coma for any etiology (life expectancy of six months or less) if they meet any three (3) of the following on day three of coma: Abnormal brain stem response Absent verbal response Absent withdrawal response to pain Serum creatinine >1.5 mg 2. Documentation of the following factors will support eligibility for hospice care: Documentation of medical complications, in the context of progressive clinical decline, within the previous 12 months, which support a terminal prognosis: Aspiration pneumonia; Pyelonephritis; Refractory stage 3-4 decubitus ulcers; Fever recurrent after antibiotics. 3. Documentation of diagnostic imaging factors which support poor prognosis after stroke include: For non-traumatic hemorrhagic stroke: Large-volume hemorrhage on CT (i.e., infratentorial > 20 ml.; supratentorial > 50 ml. Hospice Care Jan 11 12

13 Ventricular extension of hemorrhage; Surface area of involvement of hemorrhage greater than or equal to 30% of cerebrum; Midline shift greater than or equal to 1.5 cm.; Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt. 4. For thrombotic/embolic stroke: Large anterior infarcts with both cortical and subcortical involvement; Large bihemispheric infarcts; Basilar artery occlusion; Bilateral vertebral artery occlusion Dementia due to Alzheimer s Disease and Related Disorders Patients will be considered to be in the terminal stage of dementia (life expectancy of six months or less) if they meet the following criteria. 1. Patients with dementia should show all the following characteristics: Stage seven or beyond according to the Functional Assessment Staging Scale; (see Appendix A) Unable to ambulate without assistance; Unable to dress without assistance; Unable to bathe without assistance; Urinary and fecal incontinence, intermittent or constant; No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to six or fewer intelligible words. 2. Patients should have had one of the following within the past 12 months: Aspiration pneumonia; Pyelonephritis; Septicemia; Decubitus ulcers, multiple, stage 3-4; Fever, recurrent after antibiotics; Hospice Care Jan 11 13

14 Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin < 2.5 gm/dl. Note: This section is specific for Alzheimer s disease and Related Disorders, and is not appropriate for other types of dementia. End Stage HIV Disease Patients will be considered to be in the terminal stage of HIV disease (life expectancy of six months or less), if they meet the following criteria: (1 and 2 must be present; factors from 3 will add supporting documentation) 1. CD4+ count less than 25 cells/mcl or persistent viral load of greater than 100,000 copies/ml, plus one of the following: CNS lymphoma; Untreated, or not responsive to treatment, wasting (loss of at least 10% lean body mass); Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused; Progressive multifocal leukoencephalopathy; Systemic lymphoma, with advance HIV disease and partial response to chemotherapy; Visceral Kaposi s sarcoma unresponsive to therapy; Renal failure in the absence of dialysis; Cryptosporidium infection; Toxoplasmosis, unresponsive to therapy. 2. Decreased performance status, as measured by the Karnofsky Performance Status (KPS) scale, < 50% (see Appendix B) 3. Documentation of the following factors will support eligibility for hospice care: Chronic persistent diarrhea for one year; Persistent serum albumin, < 2.5; Concomitant, active substance abuse; Age greater than 50 years; Absence of or resistance to antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease; Advanced AIDS dementia complex; Toxoplasmosis; Congestive heart failure, symptomatic at rest Advanced liver disease. End Stage Adult Failure to Thrive Syndrome Hospice Care Jan 11 14

15 Patients will be considered to be in the terminal stage of adult failure to thrive syndrome (life expectancy of six months or less), if they meet all of the following: 1. Nutritional impairment is severe enough to impact the patient s weight, such that the BMI is < 22 kg/m2, and the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake. 2. The individual is significantly disabled as demonstrated by a Karnofsky or Palliative Performance Scale value < 40% Codes Related To This Policy ICD9 Codes Too numerous to list (This is not all-inclusive) V66.7 Encounter for palliative care CPT Codes N/A Revenue Codes 0651 Routine Home Care 0652 Continuous Home Care 0655 Inpatient Respite Care 0656 General Inpatient Care (Non-Respite) 0657 Physician Services (Hospice) HCPCS Codes S9122 Home health aide or certified nurse assistant, providing care in the home; per hour (Continuous Care) S9123 Nursing care, in the home; by registered nurse, per hour (Continuous Care) S9124 Nursing care, in the home; by licensed practical nurse, per hour (Continuous Care) S9125 Respite Care in the home, per diem S9126 Hospice Care in the home, per diem (Routine Hospice Care) G0337 Hospice evaluation and counseling services, pre-election Scientific Rationale The National Hospice and Palliative Care Organization defines hospice as support and care for persons in the last phase of an incurable disease so that they may live as fully and comfortably as possible. Hospice programs provide state-of-the-art palliative care and supportive services to individuals at the end of their lives, their family members and significant others, 24 hours a day, seven days a week, in both the home and facility-based settings. Physical, social, spiritual and emotional care are provided by a clinically-directed interdisciplinary team consisting of patients and their families, professionals and volunteers during the: (1) last stages of an illness; (2) dying process; and (3) bereavement period. Hospice is a specialized health care program for terminally ill patients who chose supportive and palliative care rather than curative measures and aggressive Hospice Care Jan 11 15

16 treatments for their terminal illness. It focuses on symptom control, pain management and psychosocial support for patients with a life expectancy of less than 6 months. Hospices do nothing to speed up or slow down the dying process. Rather, Hospice programs provide state-of-the-art palliative care and supportive services to individuals at the end of their lives, their family members and significant others, 24 hours a day, seven days a week, in both the home and facility-based settings. It consists of a physician-directed, nurse-coordinated interdisciplinary team consisting of social workers, counselors, home health aides, clergy, physical and occupational therapists, and specially trained volunteers. The American Board of Hospice and Palliative Medicine defines palliative care as a discipline and model of care devoted to achieve the best possible quality of life of the patient and family throughout the course of a life-threatening illness through the relief of suffering and the control of symptoms. Such relief requires the comprehensive assessment and interdisciplinary team management of the physical, psychological, social, and spiritual needs of patients and their families. Palliative medicine helps the patient and family face the prospect of death assured that comfort will be a priority, values and decisions will be respected, spiritual and psychosocial needs will be addressed, practical support will be available, and opportunities will exist for growth and resolution. Palliative care is operationalized through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs and culture(s). Evaluation and treatment is comprehensive and patient-centered, with a focus on the central role of the family unit in decision-making. Palliative care affirms life by supporting the patient and family s goals for the future, including their hopes for cure or life-prolongation, as well as their hopes for peace and dignity throughout the course of illness, the dying process and death. Palliative care aims to guide and assist the patient and family in making decisions that enable them to work toward their goals during whatever time they have remaining. Comprehensive palliative care services often require the expertise of various providers in order to adequately assess and treat the complex needs of seriously ill patients and their families. Members of a palliative care team may include professionals from medicine, nursing, social work, chaplain visits, nutrition, rehabilitation, pharmacy and other professional disciplines. Leadership, collaboration, coordination and communication are key elements for effective integration of these disciplines and services. Treatments rendered with the primary purpose of curing the illness or treatments, which extend the length of life, while compromising the quality of the time remaining, are contrary to the Hospice philosophy of care. Review History September 27, 2005 March 2007 September 2007 January 2011 Medical Advisory Council Coding Updates Policy Update No revisions Numerous revisions to policy criteria. Added Medicare table Patient Education Websites English 1. MedlinePlus. Hospice Care. Available at: Hospice Care Jan 11 16

17 2. Hospice Foundation of America. What is Hospice? Available at: 3. The National Hospice and Palliative Care Organization (NHPCO). Hospice & Palliative Care Information. Available at: Spanish 1. MedlinePlus. Cuidado en hospicios. Available at: 2. Cómo localizar los servicios para pacientes desahuciados. Qué son los servicios para pacientes desahuciados? Available at: 3. Llame a Hospice de Muskegon-Oceana. Available at: This policy is based on the following evidence-based guidelines: 1. Clinical Practice Guidelines For Quality Palliative Care. Brooklyn (NY): National Consensus Project for Quality Palliative Care; Second Edition Available at: 2. Guidelines for Hospice Care and Treatment Available at: 3. Keay TJ, Schonwetter RS. Hospice Care in the Nursing Home. American Family Physician Vol. 57/No. 3 (February 1, 1998). Available at: 4. National Hospice Organization. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases Available at: 5. The care of dying patients: a position statement from the American Geriatrics Society. J Am Geriatr Soc 1995;43: Available at: References Update January Candy B, Holman A, Leurent B, et al. Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. Int J Nurs Stud Jan;48(1): Reville B, Miller MN, Toner RW, Reifsnyder J. End-of-life care for hospitalized patients with lung cancer: utilization of a palliative care service. J Palliat Med Oct;13(10): Torke AM, Holtz LR, Hui S, et al. Palliative care for patients with dementia: a national survey. Am Geriatr Soc Nov;58(11): References 1. Bookbinder M, Blank AE, Arney E, et al. Improving End-of-Life Care: Development and Pilot-Test of a Clinical Pathway. J Pain Symptom Manage Jun;29(6): Dobratz MC. Gently into the light: a call for the critical analysis of end-of-life outcomes. ANS Adv Nurs Sci Apr-Jun;28(2): Ryder-Lewis M. Going home from ICU to die: a celebration of life. Nurs Crit Care May-Jun;10(3): Hospice Care Jan 11 17

18 4. Oliver DP, Porock D, Zweig S. End-of-Life Care in U.S. Nursing Homes: A Review of the Evidence. J Am Med Dir Assoc May-Jun;6(3 Suppl):S Levy MH, Samuel TA. Management of cancer pain. Semin Oncol Apr;32(2): Sethi S. Hospice: an underutilized resource. J Okla State Med Assoc Mar;94(3): Lynn J, Harrell F Jr, Cohn F, Wagner D, Connors AF Jr. Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy. New Horiz 1997;5: Lynn J. Measuring quality of care at the end of life: a statement of principles. J Am Geriatr Soc 1997; 45: Harris NJ, Dunmore R, Tscheu MJ. The Medicare Hospice Benefit: fiscal implications for hospice program management. Cancer Manage 1996;3: Cranmer KW. Hospice care in long-term care facilities: a gerontologist's viewpoint. Nurs Home Med 1996;4: Leland J. The nursing home Medicare Hospice Benefit. Nurs Home Econ 1996;3: Schonwetter RS. Care of the dying geriatric patient. Clin Geriatr Med 1996;12: Fortinsky RF, Raff L. Physicians in nursing homes: challenges and opportunities. Nurs Home Med 1996;4: Ferrell BA, Ferrell BR, Rivera L. Pain in cognitively impaired nursing home patients. J Pain Symptom Manage 1995;10: Leibowitz C, Browing S. The expanded team--hospice in the LTC facility. Am J Hospice Palliat Care 1995;12: O'Brien LA, Grisso JA, Maislin G, LaPann K, Krotki KP, Greco PJ, et al. Nursing home residents' preferences for life-sustaining treatments. JAMA 1995;274: Leland J. Terminal care in the nursing home part I: identifying the terminally ill and managing their pain. Nurs Home Med 1994;2: Leland J. Terminal care in the nursing home part II: management of symptoms other than pain. Nurs Home Med 1994;2: Amar DF. The role of the hospice social worker in the nursing home setting. Am J Hospice Palliat Care 1994;11: Keay TJ, Fredman L, Taler GA, Datta S, Levenson SA. Indicators of quality medical care for the terminally ill in nursing homes. J Am Geriatr Soc 1994;42: Engle VF, Graney MJ. Predicting outcomes of nursing home residents: death and discharge home. J Gerontol 1993;48:S Hurley AC, Volicer BJ, Hanrahan PA, Houde S, Volicer L. Assessment of discomfort in advanced Alzheimer patients. Res Nurs Health 1992;15: Reisberg B. Functional assessment staging (FAST). Psychopharmacol Bull 1988;24: Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the Hospice Care Jan 11 18

19 facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this " Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, new or revised policies require prior notice or posting on the website before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, new or revised policies require prior notice or website posting before an amendment is deemed effective. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. Coverage decisions are the result of the terms and conditions of the Member s benefit contract. The Policies do not replace or amend the Member s contract. If there is a discrepancy between the Policies and the Member s contract, the Member s contract shall govern. Policy Limitation: Legal and Regulatory Mandates and Requirements. The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Policy Limitations: Medicare and Medicaid. Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Hospice Care Jan 11 19

20 Fast Stage Appendix A Functional Assessment Staging 1984 by Barry Reisberg, M.D. Functional Assessment 1 No difficulties, either subjectively or objectively a 6b 6c 6d 6e 7a 7b 7c 7d 7e 7f Complains of forgetting location of objects; subjective word finding difficulties only. Decreased job functioning evident to coworkers; difficulty in traveling to new locations. Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances; marketing). Requires assistance in choosing proper clothing for the season or occasion. Difficulty putting clothing on properly without assistance. Unable to bathe properly; may develop fear of bathing. Will usually require assistance adjusting bath water temperature. Inability to handle mechanics of toileting (i.e., forgets to flush; doesn't wipe properly). Urinary incontinence, occasional or more frequent. Fecal incontinence, occasional or more frequent. Ability to speak limited to about half a dozen words in an average day. Intelligible vocabulary limited to a single word in an average day. Nonambulatory (unable to walk without assistance). Unable to sit up independently. Unable to smile. Unable to hold head up. NOTE: Functional staging score = Highest FAST Stage checked Hospice Care Jan 11 20

21 Appendix B Karnofsky Performance Scale 100 Normal, no complaints, no evidence of disease 90 Able to carry on normal activity: minor symptoms of disease 80 Normal activity with effort: some symptoms of disease 70 Cares for self: unable to carry on normal activity or active work 60 Requires occasional assistance but is able to care for needs 50 Requires considerable assistance and frequent medical care 40 Disabled: requires special care and assistance 30 Severely disabled: hospitalization is indicated, death not imminent 20 Very sick, hospitalization necessary: active treatment necessary 10 Moribund, fatal processes progressing rapidly 0 Dead Hospice Care Jan 11 21