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    v1.0.28
    OpenPayerPolicy UpdatesHome Health & HospiceAmbetter Nevada Hospice Coverage Prior Auth | Open…
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    CurrentAmbetter NevadaPolicy CP.MP.54

    Hospice Services (Clinical Policy)

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    Medical necessity criteria, required documentation, levels of hospice care, certification periods, and services considered not medically necessary for members/enrollees seeking hospice care.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Policy Summary
    PayerAmbetter Nevada
    PolicyHospice Services (Clinical Policy)
    Policy CodePolicy CP.MP.54
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization before initiating hospice services and specify the level of care and dates.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysinitial hospice certification period
    6 monthslife expectancy threshold
    PPS/KPS < 70%performance threshold
    8 hoursmin nursing for continuous care
    5 daysmax inpatient respite days

    Hospice Coverage Criteria

    inv-01: Initial Request

    Covered when ALL of the following are met

    Initial request overall: I. Required documentation submitted (including hospice medical director certification for the initial 90-day period identifying the terminal diagnosis and statement that life expectancy is six months or less if the condition runs its normal course). II. Member meets ONE of the listed severity of illness criteria (Cancer; ALS; Heart Disease; Pulmonary Disease; Dementia; HIV; Liver Failure; Acute or Chronic Renal Failure; Stroke; Coma; Non-Disease Specific Decline). III. Requested intensity of service appropriate for one of: Routine Hospice Home Care, Continuous Hospice Home Care, Inpatient Respite Hospice Care, or General Inpatient Short-Term (non-respite) Hospice Care.

    Only one level of care may be authorized per day.

    inv-02: Severity: Cancer

    Covered when ALL of the following are met

    Cancer: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs (e.g., ambulation, continence, transfers, dressing, feeding, bathing). 3) Disease status one of: (a) metastatic cancer at presentation deferring therapy; (b) progression to metastatic disease with decline despite or deferring therapy; (c) brain, pancreatic, or small cell lung cancer.

    inv-03: Severity: ALS

    Covered when ALL of the following are met

    ALS: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs (e.g., ambulation, continence, transfers, dressing, feeding, bathing). 3) Disease status one of: (a) signs/symptoms of impaired respiratory function and not electing tracheostomy/invasive ventilation with FVC < 30% (if available); (b) rapid progression with ≥5% body weight loss (with or without tube feeding); (c) rapid progression with life‑threatening complications (sepsis, recurrent aspiration, pyelonephritis, stage 3–4 decubiti).

    inv-04: Severity: Heart Disease

    Covered when ALL of the following are met

    Heart Disease: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs. 3) Disease status examples include: (a) CHF: symptomatic at rest (NYHA Class IV) with EF < 20% (if available) and presently optimally treated with diuretics and vasodilators or failed therapy with IV inotropes; (b) CAD: elderly with intractable angina not candidate for revascularization and not responding to appropriate medications and not a candidate for transplant.

    inv-05: Severity: Pulmonary Disease

    Covered when ALL of the following are met

    Pulmonary Disease: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs. 3) Severity: disabling symptoms at rest or with minimal exertion, diminished functional capacity (e.g., bed‑to‑chair), and FEV1 < 30% predicted after bronchodilator (if obtainable). 4) Progressiveness: two ED visits in prior 6 months or one hospitalization in last year for pulmonary infection and/or respiratory failure with intubation or BiPAP, and member states they do not want to be intubated. 5) ABG criteria: PaO2 ≤ 55 mmHg or SaO2 ≤ 88% at rest on room air, or PaCO2 ≥ 50 mmHg.

    inv-06: Severity: Dementia

    Covered when ALL of the following are met

    Dementia: 1) FAST stage 7 or beyond. 2) Increasing medical complications with at least one in the past 12 months: aspiration pneumonia; pyelonephritis or other upper urinary tract infection; septicemia; multiple stage 3–4 decubiti; recurrent fever after a course of antibiotics; weight loss >10% in prior 6 months; or albumin <2.5 g/dL.

    inv-07: Severity: HIV

    Covered when ALL of the following are met

    HIV: 1) CD4+ T‑cell count < 25 or viral load > 100,000 copies/mL. 2) PPS or KPS score < 50%. 3) At least one AIDS‑related condition (e.g., CNS or poorly responsive systemic lymphoma; wasting ≥10% lean body mass; MAC bacteremia; progressive multifocal leukoencephalopathy; refractory visceral Kaposi's sarcoma; renal failure without dialysis; refractory cryptosporidium; refractory toxoplasmosis).

    inv-08: Severity: Liver Disease

    Covered when ALL of the following are met

    Liver Disease: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs. 3) End‑stage liver disease and not on transplant list. 4) PT > 5 seconds or INR > 1.5. 5) Albumin < 2.5 g/dL. 6) At least one complication: recurrent bleeding esophageal varices despite therapy; refractory ascites; episode of spontaneous bacterial peritonitis; hepatorenal syndrome; or hepatic encephalopathy.

    inv-09: Severity: Renal Failure

    Covered when ALL of the following are met

    Acute or Chronic Renal Failure: 1) PPS or KPS score < 70%. 2) Dependence for at least two ADLs. 3) Member is in renal failure and not receiving dialysis AND either (a) serum creatinine > 8 mg/dL (> 6 mg/dL if diabetes) or (b) creatinine clearance < 15 mL/min.

    inv-10: Severity: Stroke

    Covered when ALL of the following are met

    Stroke: 1) PPS or KPS score < 40%. 2) Inadequate oral intake with one of: (a) weight loss >10% in last 6 months or >7.5% in last 3 months; (b) serum albumin <2.5 g/dL; (c) recurrent aspiration; (d) dysphagia with declining tube feeding and hydration.

    inv-11: Severity: Coma

    Covered when ALL of the following are met

    Coma: Member is comatose with at least three of the following on day three of coma: abnormal brain stem response; absent verbal response; absent withdrawal to painful stimuli; creatinine > 1.5 mg/dL.

    inv-12: Severity: Non-Disease Specific Decline

    Covered when ALL of the following are met

    Non-Disease Specific Decline: 1) Irreversible decline based on baseline and follow‑up determinations. 2) Clinical deterioration of one or more: progressive dependence for ADLs; KPS or PPS < 70%; increasing ER visits or hospitalizations; worsening clinical status/signs/symptoms/labs (e.g., recurrent infections, progressive weight loss, dysphagia, decreasing albumin); or progressive/stage 3–4 decubiti.

    Consider significant comorbidities when applying these criteria.

    inv-13: Covered hospice services

    Covered when the hospice coverage criteria are met and the member/enrollee is determined to be terminally ill and under a hospice plan of care:

    Certification periods: Initial 90‑day period, second 90‑day period, then unlimited 60‑day periods; hospice care is continuous between periods unless revoked or discharged.
    Services included: Physician services; appropriate skilled nursing; home health aide; physical and/or occupational therapy; speech therapy for dysphagia/feeding; medical social services; counseling (including bereavement); short‑term inpatient care; prescription drugs necessary for palliation/management of the terminal illness; and consumable medical supplies used by the hospice team.

    inv-14: Level of care criteria

    Level-of-care definitions and limits:

    Continuous home care: Primarily skilled nursing during brief crisis periods to achieve palliation or manage acute medical symptoms; minimum 8 hours of nursing care in a 24‑hour period (begins and ends at midnight); at least 50% of total care must be provided by a nurse; care must be predominantly nursing rather than ADL assistance; may be supplemented by home health aide/homemaker services.>= 8 nursing hours/24h; >=50% nursing of total care

    Continuous care is not intended as respite or an alternative to paid caregivers or placement.

    Inpatient respite: Short‑term inpatient care in an approved facility for up to five consecutive days per episode to relieve primary caregivers; not residential or custodial care.<= 5 consecutive days per episode
    General inpatient (non-respite): Short‑term facility‑based care for pain control and symptom relief related to the terminal diagnosis that cannot be managed at home; goal is to stabilize the member and return them to the home environment.

    Primary diagnosis of debility or failure to thrive is explicitly listed as a circumstance in which hospice services are considered not medically necessary. The policy identifies both “debility” and “unspecified debility” as primary diagnoses that do not meet hospice medical necessity criteria and therefore are exclusions to coverage.

    This exclusion should be applied when the member’s documented principal diagnosis is one of these terms and there is no additional qualifying disease-specific severity criterion documented that would otherwise meet hospice eligibility requirements.

    Services provided during an acute inpatient stay for a diagnosis that is unrelated to the terminal illness are not covered as part of hospice. The policy clarifies that inpatient services for a separate acute condition should be billed and evaluated under the appropriate inpatient benefit rather than hospice.

    Separately, hospice services are not covered when the member is no longer considered terminally ill as documented in the medical record. Revocation of hospice election or discharge from hospice for reasons such as loss of terminal status, refusal of services, relocation, or transfer to a non-covered hospice program are also non-covered scenarios.

    When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid provisions take precedence. Providers should consult the applicable state Medicaid manual for any differing coverage provisions that govern hospice benefits for Medicaid enrollees.

    For Medicare members, the policy also directs reviewers to check applicable Medicare National and Local Coverage Determinations and related CMS guidance prior to applying the criteria in this policy to ensure consistency with federal coverage rules.

    Examples of situations considered not medically necessary include cases where the primary diagnosis is recorded as debility, unspecified debility, or failure to thrive. In these instances, hospice care is not supported unless there is additional, documented disease-specific evidence that meets one of the policy’s listed severity criteria.

    A reviewer should deny hospice coverage when the documentation shows the primary diagnosis falls into these categories and no qualifying severity criteria (e.g., disease-specific markers, performance scale thresholds, dependence in ADLs) are present to support terminal prognosis and hospice intensity-of-service needs.

    Services, supplies, procedures or medications that are directed toward curing the terminal condition are not covered as part of hospice care. The policy makes a specific exception for children enrolled in Medicaid or CHIP who may receive concurrent curative care.

    For adults, any treatment documented as intended to cure rather than palliate the terminal diagnosis should be excluded from hospice coverage and pursued under the appropriate medical benefit rather than the hospice benefit.

    Coding and Billing Codes

    Routine Hospice Home CareHCPCS | RevenueCovered
    T2042Routine hospice home care
    rev 0651Revenue code for routine hospice home care
    Continuous Hospice Home CareHCPCS | RevenueCovered
    T2043Continuous hospice home care
    rev 0652Revenue code for continuous hospice home care
    Inpatient Respite Hospice CareHCPCS | RevenueCovered
    T2044Inpatient respite hospice care
    rev 0655Revenue code for inpatient respite hospice care
    General Inpatient Short-Term Hospice CareHCPCS | RevenueCovered
    T2045General inpatient, short-term hospice care (non-respite)
    rev 0656Revenue code for general inpatient hospice care
    Informational hospice CPT/HCPCS codesmixed
    T2042Hospice routine home care; per diem
    T2043Hospice continuous home care; per hour
    T2044Hospice inpatient respite care, per diem
    T2045Hospice general inpatient care; per diem
    T2046Hospice long-term care, room and board only; per diem
    G0337Hospice evaluation and counseling services, pre-election
    0651Hospice routine home care; per diem
    0652Hospice continuous home care, per 15 minutes
    Revenue codesmixed
    0655Hospice inpatient respite care, per diem
    0656Hospice general inpatient, non-respite care, per diem
    0658Hospice room and board, nursing facility
    0657Hospice charges for services furnished to patients by physician or nurse practitioner employees, or physicians or nurse practitioners receiving compensation from the hospice
    PPS/KPS performance threshold — commonly required across diagnoses
    Performance threshold (general)Palliative Performance Scale (PPS) or Karnofsky Performance Status (KPS) score < 70% is commonly required across diagnoses.
    Stroke-specific thresholdFor stroke, the required PPS or KPS threshold is < 40%.
    HIV-specific thresholdFor HIV, a PPS or KPS threshold of < 50% is required in that section.
    Use of validated scalesEligibility determinations reference validated performance measures (PPS or KPS) to assess prognosis and function.
    Nursing hours for continuous care

    Provider Requirements, Authorization & Documentation

    Prior Authorization

    Prior Authorization Required

    Authorization is required before initiating hospice services and for each subsequent change in the level of hospice service. Specify the requested level of care and the exact dates of service. Only one level of care may be authorized for each day of hospice care. Coverage decisions are subject to the member's plan terms, conditions, exclusions and limitations and to applicable state Medicaid and federal Medicare rules.

    • Obtain authorization to provide hospice services before care is initiated.
    • Request authorization for initial hospice admission and specify level of care (Routine, Continuous Home Care, Inpatient Respite, or General Inpatient) and dates.
    • Obtain authorization for each change in level of intensity of service and for subsequent recertification periods.
    • Only one level of care may be authorized per calendar day; bill the appropriate HCPCS or revenue code per contract.
    • Coverage and authorization requirements may vary for Medicare and Medicaid — follow applicable NCDs, LCDs and state Medicaid manual provisions.

    Key Definitions

    Hospice — coordinated, integrated program by a multidisciplinary team
    DefinitionHospice is a coordinated, integrated program developed by a multidisciplinary team to provide end-of-life care focused on relief of pain and symptoms related to the terminal diagnosis for members with life expectancy of six months or less.
    Team compositionCare is provided by a multidisciplinary team including physicians, skilled nurses, home health aides, therapists, social services, and counseling staff.
    Plan of careServices are provided under a hospice plan of care designed by the multidisciplinary team to meet the needs of the terminally ill member and their family.
    Levels of care
    Routine Hospice Home CareCare provided in the member's home (or approved residence) for the terminal diagnosis; medically necessary when < eight hours of nursing care are required in a 24-hour period (HCPCS T2042 or rev 0651).

    Background and Scope

    The hospice program provides coordinated, multidisciplinary end-of-life care with an emphasis on relief of pain and other distressing symptoms related to a documented terminal diagnosis. Care is organized around an individualized plan of care developed and overseen by the hospice interdisciplinary team.

    Covered hospice services commonly include physician and skilled nursing services, home health aide, therapies for symptom-related needs (physical/occupational/speech for dysphagia), medical social services, counseling (including bereavement), short-term inpatient care when required for symptom control, and medications and supplies necessary for palliation and management of the terminal illness.

    Policy Revision History

    06/25 (year not stated in header)Annual review / RevisionLatest

    Annual review and references updated (Revision Date = 06/25; Approval Date = 06/25).

    06/24Annual review / Revision

    Annual review with revisions to criteria II.D.3.c (added 'after bronchodilator (if able to obtain)'), updates to II.E.2.b, II.E.2.f, II.G terminology, and II.I.2.a wording; references reviewed and updated (Revision Date = 06/24; Approval Date = 06/24).

    07/23
    Policy Summary
    PayerAmbetter Nevada
    PolicyHospice Services (Clinical Policy)
    Policy CodePolicy CP.MP.54
    Change TypeNo material changes
    Effective Date
    Next Review Date
    Key ActionObtain prior authorization before initiating hospice services and specify the level of care and dates.
    SourceLink
    On This Page
    Hospice Coverage CriteriaCoding and Billing CodesProvider Requirements, Authorization & DocumentationKey DefinitionsBackground and ScopePolicy Revision History
    Up to 5 days per episode (with ongoing concurrent review for additional days)
    Minimum nursing hours>= 8 hours of nursing care in a 24-hour period is required for continuous hospice home care.
    Nursing proportion of total careAt least 50% of the total continuous care must be provided by a nurse (care must be predominantly nursing rather than ADL assistance).
    24-hour period definitionThe 24-hour period for counting nursing hours begins and ends at midnight.
    Supplemental servicesContinuous care may be supplemented by home health aide or homemaker services but these cannot constitute the majority of care.
    Minimum nursing hours for continuous home care
    Minimum nursing hours per 24 hours>= 8 hours of nursing care in a 24-hour period (begins and ends at midnight).
    Nursing need need not be continuousThe required nursing hours need not be continuous across the 24-hour period.
    PurposeContinuous hospice home care is intended to maintain the member at home during brief crisis periods for palliation or acute symptom management.
    Documentation Required

    Required Documentation for Initial Request and Recertification

    Submit complete clinical documentation to support initial hospice admission and any recertifications or changes in level of care. Documentation must demonstrate terminal prognosis, clinical findings supporting life expectancy ≤ six months if the disease follows its normal course, and the hospice election statement.

    • Written hospice medical director certification for the initial 90-day certification period identifying the terminal diagnosis and clinical findings supporting life expectancy of six months or less.
    • Hospice election statement signed by the member/enrollee or the member/enrollee's healthcare proxy acknowledging understanding of hospice care.
    • For recertification: renewed hospice medical director certification of terminal illness for each subsequent 90‑day period.
    • Clinical documentation supporting requested level of care (e.g., hours of nursing required, acute symptom management needs) and any change in condition.
    • Notify the health plan of any significant change in the member/enrollee's status, treatment plan or goals.
    Note

    Review Applicable Medicare/Medicaid Guidance Before Authorization

    Providers must review and follow applicable Medicare NCDs/LCDs, Medicare Benefit and Claims Processing Manuals, and state Medicaid rules when submitting authorization requests or determining coverage. Plan-level administrative policies and the member's contract govern coverage where applicable.

    • Review CMS Medicare Benefit Policy Manual Chapter 9 and Claims Processing Manual Chapter 11 prior to authorizations and claims.
    • Check applicable Local Coverage Determinations (LCDs) (e.g., Hospice Determining Terminal Status) and National Coverage Determinations (NCDs).
    • For Medicaid members/enrollees, follow state Medicaid manual provisions when they conflict with this policy.
    • Follow plan-level administrative policies and contract provisions when billing (appropriate HCPCS or revenue codes).
    Denial Risk

    Denial Risk & Coverage Conditions

    Services may be denied when hospice clinical or administrative requirements are not met. Providers risk denial if authorization is not obtained prior to initiation or if documentation is insufficient to support terminal prognosis or requested level of care.

    • Denial risks include: primary diagnosis of debility or failure to thrive; member no longer terminally ill; services directed toward curing the terminal condition (except for children under Medicaid/CHIP); revoked hospice election; or discharge from hospice.
    • Failure to obtain prior authorization before initiating hospice care may result in denial or nonpayment.
    • Incomplete or missing certification, signed election statement, or clinical evidence supporting the requested level of care may lead to denial.
    Continuous Hospice Home Care
    Primarily skilled nursing at home during brief crisis periods when >= eight hours of nursing care in a 24-hour period are required (HCPCS T2043 or rev 0652).
    Inpatient Respite Hospice CareShort-term inpatient care in an approved facility to relieve primary caregivers for up to five consecutive days per episode (HCPCS T2044 or rev 0655).
    General Inpatient (short-term)Facility-based short-term care for acute symptom management or pain control related to the terminal diagnosis when care cannot be managed at home (HCPCS T2045 or rev 0656).
    Continuous hospice home care
    Primary purposeContinuous hospice home care consists primarily of skilled nursing during brief crisis periods to achieve palliation or manage acute medical symptoms and to maintain the member at home.
    Nursing hours requirementRequires a minimum of eight hours of nursing care in a 24-hour period; nursing need not be continuous.
    Care compositionAt least 50% of total care must be provided by a nurse; care must be predominantly nursing rather than personal care/ADL assistance.
    Inpatient respite hospice care
    PurposeInpatient respite hospice care provides short-term inpatient services in an approved facility to relieve the primary caregiver's duties.
    Duration limitRespite care is authorized for no more than five consecutive days per episode.
    SettingProvided in an approved inpatient hospice facility, hospital, or nursing home and is not residential or custodial care.
    General inpatient hospice care
    PurposeGeneral inpatient, short-term hospice care is provided for pain control and symptom relief related to the terminal diagnosis when such care cannot be managed at home.
    Treatment focusThe individual treatment plan is specifically directed at acute symptom management and/or pain control with the goal of stabilizing and returning the member to home.
    Setting and approvalProvided in an approved hospice facility, hospital, or nursing home; up to five days may be approved with concurrent review for additional days.
    LCD — Local Coverage Determination
    DefinitionLocal Coverage Determination (LCD) — Medicare determinations that may guide terminal status and hospice coverage decisions.
    Examples citedThe policy references specific LCDs such as 'Hospice Determining Terminal Status (L34538)' and other LCD guidance for hospice terminal status determinations.
    Provider actionReview applicable NCDs and LCDs prior to applying policy criteria and during authorization and claims submission.
    Performance scales — PPS and Karnofsky referenced
    Referenced performance scalesPalliative Performance Scale (PPS) and Karnofsky Performance Status (KPS) are referenced as validated performance measures to assess prognosis and eligibility.
    Use in criteriaPPS or KPS scores are used across multiple severity criteria (e.g., general <70% threshold; stroke <40%; HIV <50% in its section).
    External sourcesPolicy cites external resources describing PPS and KPS (Medicare manuals and PPS/KPS references) for clinician guidance.

    Hospice is a coordinated, multidisciplinary program provided by a team of professionals to deliver end-of-life care focused on symptom relief for members with a life expectancy of six months or less if the terminal diagnosis runs its normal course. Services are delivered according to a hospice plan of care and are intended to prioritize comfort and palliation rather than curative treatments.

    Most hospice services are provided in the member’s home by licensed hospice providers under the direction of an attending physician, with an interdisciplinary team coordinating medical, nursing, psychosocial and supportive services aimed at quality of life during the terminal phase.

    Annual review / Revision

    Annual review and references reviewed and updated; reviewed by internal specialist (Revision Date = 07/23; Approval Date = 07/23).

    12/22Annual review / Revision

    Annual review and references reviewed and updated with minor edits of no clinical significance (Revision Date = 12/22; Approval Date = 12/22).

    12/21Revision / Annual review

    References reviewed and updated; changes included revising forced vital capacity (FVC) threshold in II.B.3 and other edits (Revision Date = 12/21; Approval Date = 12/21).

    03/21Revision

    Replaced 'glomerular filtration rate' with creatinine clearance in renal criteria and updated references; policy reorganized and codes reviewed (Revision Date = 03/21; Approval Date = 04/21).

    07/14Reorganization / Revision

    Policy reorganized into severity of illness and intensity of service criteria and appendices added (Revision Date = 07/14; Approval Date = 07/14).