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Diagnosis Guidelines
The following Diagnosis Guidelines are for the most common illnesses. The guidelines are not required criteria for admission, but rather are guidelines adopted by the Centers for Medicare and Medicaid Services to assist physicians in determining hospice appropriateness.
Criterion 1: Medical Indicators
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A CD4+ Count below 25 cells/mcL or a persistent viral load greater than 100,000 copies/ml.
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The patient must also exhibit one or more of the following conditions:
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Central Nervous System (CNS) lymphoma
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Untreated or treatment-resistant wasting syndrome (loss of 33% lean body mass)
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Mycobacterium avium complex (MAC) bacteremia, either untreated, unresponsive to treatment, or treatment refused
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Progressive multifocal leukoencephalopathy
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Systemic lymphoma with partial response to chemotherapy, accompanying advanced HIV
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Visceral Kaposi’s sarcoma unresponsive to treatment
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Renal failure without the option of dialysis
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Cryptosporidium infection
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Toxoplasmosis, unresponsive to treatment
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Criterion 2: Performance Status
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The patient’s performance status, as per the Karnofsky Performance Status (KPS) scale, must be 50 or below.
Criterion 3: Supporting Documentation (Optional)
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Chronic persistent diarrhea lasting one year
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Serum albumin levels persistently below 2.5
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Ongoing substance abuse
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Age over 50 years
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Absence of specific HIV-related therapies, including antiretroviral, chemotherapeutic, and prophylactic treatments
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Advanced AIDS dementia complex
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Symptomatic congestive heart failure at rest
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Chronic persistent diarrhea
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Criterion 1: Definitive Diagnosis
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Patient has a confirmed tissue diagnosis of cancer, which may include metastatic disease.
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The patient has either received optimal treatment for their cancer, is not interested in further treatment, or both.
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The patient has participated in a clinical trial or investigational protocol and did not achieve a successful outcome, and does not wish to pursue further treatment.
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The patient is not a candidate for any further cancer treatment.
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The patient has experienced severe side effects from treatment, such as radiation burns, pain, nausea, vomiting, or fatigue, and chooses not to continue treatment.
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The patient has opted for care focused on symptom management over curative measures.
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The patient or their family has decided to prioritize quality of life over extending life.
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The patient or their family prefers palliative care or comfort measures only.
Criterion 2: Presumptive Diagnosis
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Diagnostic imaging has revealed a mass or multiple lesions indicative of advanced, widespread cancer.
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The patient is not considered a candidate for aggressive chemotherapy or radiation therapy.
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The patient or their family has declined any further treatment.
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The patient or their family has opted for palliative care or symptom management only.
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Criterion 1: Treatment and Symptom Assessment
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At the time of initial certification or recertification for hospice, the patient must be optimally treated with diuretics and vasodilators, which may include Angiotensin-converting enzyme (ACE) inhibitors or a combination of hydralazine and nitrates. If side effects such as hypotension or hyperkalemia prevent the use of these medications, this must be documented in the medical records.
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The patient experiences angina pectoris at rest, which is resistant to standard nitrate therapy. Additionally, the patient is either not a candidate for or has declined invasive procedures.
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The patient is unable to engage in any physical activity without experiencing symptoms, which are present even at rest, and worsen with any physical exertion.
Criterion 2: Advanced Cardiac Symptoms
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The patient exhibits significant symptoms of recurrent congestive heart failure (CHF) at rest and is classified as New York Heart Association (NYHA) Class IV.
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There is evidence of treatment-resistant symptomatic supraventricular or ventricular arrhythmias.
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The patient has a history of cardiac arrest or resuscitation.
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There is a documented history of unexplained syncope.
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There is evidence of a brain embolism of cardiac origin.
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The patient has concomitant HIV disease.
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The ejection fraction documented is 20% or less.
Criterion 3: Supporting Documentation (Optional)
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Additional documentation supporting these findings can lend further credibility to the eligibility for hospice care but is not required for qualification.
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Criterion 1: Advanced Functional Impairment
Patients must be at Stage 7 on the Functional Assessment Staging (FAST) Scale, which includes:Mobility: The patient is unable to ambulate without assistance.
Dressing: The patient cannot dress without assistance.
Bathing: The patient is unable to bathe without assistance.
Continence: The patient experiences intermittent or constant urinary and fecal incontinence.
Communication: There is no consistently meaningful verbal communication; the patient may use stereotypical phrases or speak less than six intelligible words.
Criterion 2: Significant Clinical Complications
Patients should have experienced one or more of the following within the past 12 months:Aspiration Pneumonia: An infection caused by inhaling food, stomach acid, or saliva into the lungs.
Pyelonephritis or Upper Urinary Tract Infection: A type of urinary infection that has reached the kidney.
Septicemia: Also known as blood poisoning, it's a severe and potentially life-threatening infection that has spread through the bloodstream.
Decubitus Ulcers: Multiple stage 3 or 4 pressure ulcers, indicating severe skin breakdown.
Recurrent Fever: Repeated fevers despite antibiotic treatments.
Nutritional Problems: Difficulty maintaining sufficient fluid and calorie intake, evidenced by either a 10% weight loss over the previous six months or a serum albumin level below 2.5 gm/dl.
Additional Considerations
While meeting these criteria typically qualifies a patient for hospice care, exceptions can be made for individuals with comorbidities or a rapid functional decline that might not strictly meet the above conditions. For more detailed eligibility information, please contact
