CurrentCentenePolicy HNCA.CP.MP.679

Palliative Care Eligibility Criteria (PDF)

Defines medical necessity eligibility guidelines for palliative care services for adult and pediatric members, including general criteria, disease-specific criteria (CHF, COPD, advanced cancer, liver disease), and pediatric-specific criteria. Includes informational coding examples and required palliative services.

Policy Summary

PayerCentene

PolicyPalliative Care Eligibility Criteria (PDF)

Policy CodePolicy HNCA.CP.MP.679

Change TypeClarified (no material changes)

Effective DateSep 23, 2009

Next Review Date

Key ActionDocument continued decline and diagnosis-specific data, including required measures and hospice eligibility status.

SourceLink

POLICY UPDATE CHANGES

Document indicates policy developed based on APL with dates 9/23 and notes no updates for 9/24 and 9/25.

7Minimum required palliative services listed

4Adult disease categories with explicit criteria

1Pediatric eligibility section (members under 21)

10Example procedure/diagnosis codes listed

Coverage Summary

Defines medical necessity eligibility guidelines for palliative care services for adult and pediatric members; coverage stance: covered_with_criteria. Effective date: 09/23; last review date: 9/25. The policy outlines general eligibility requirements plus disease-specific adult criteria (CHF, COPD, advanced cancer, liver disease) and pediatric criteria for members under 21.

Selected clinical thresholds and quick facts

Ejection Fraction< 30%

FEV1< 35% of predicted

24-hour O2 requirement< 3 L/min or >= 3 L/min (disease-specific thresholds)

Karnofsky Performance Scale<= 70

MELD score> 19

Serum albumin< 3.0 g/dL

INR> 1.3

Minimum required palliative services7

Adult disease categories with explicit criteria4

Pediatric eligibility section (members under 21)1

Example procedure/diagnosis codes listed10

Medical Necessity Criteria

General and Disease-Specific Eligibility

Requests for palliative care are considered medically necessary if ALL of Section A are met and, as applicable, one of Section B (adult disease-specific) or Section C (pediatric) criteria are met.

ref.

Continuation of Services

Ongoing eligibility for palliative care

Continuation of Services: If the member continues to meet the minimum eligibility criteria (adult or pediatric), the member may continue to access both palliative care and curative care until the condition improves, stabilizes, or results in death.

Provider Actions & Documentation Requirements

Documentation Required

Document continued decline and diagnosis‑specific data

Providers must document continued decline in the member's health status, including diagnosis‑specific measures as applicable (e.g., ejection fraction, FEV1, 24‑hour oxygen requirement, Karnofsky Performance Scale score, MELD score, serum albumin, INR), and document that the member is not eligible for or has declined hospice enrollment.

Ejection fraction (threshold: < 30%)
FEV1 (threshold: < 35% predicted)
24‑hour oxygen requirement (disease‑specific thresholds)
Karnofsky Performance Scale (threshold: ≤ 70)
MELD score (threshold: > 19)
Serum albumin (threshold: < 3.0 g/dL)
INR (threshold: > 1.3)
Documentation of hospice eligibility status or member decline of hospice

Documentation Required

Advance Care Planning participation

Document that the member and, if applicable, the family or designated support person agree to participate in Advance Care Planning (ACP) discussions and that they agree to attempt, when clinically appropriate, in‑home, residential, or outpatient palliative/disease management instead of first presenting to the emergency department. When billing ACP services, reference the appropriate ACP CPT codes.

99497
99498

Billing Rule

Use informational codes as appropriate

The listed CPT, HCPCS, and ICD‑10 codes are provided for informational purposes only and do not guarantee coverage. Providers should reference current professional coding guidance prior to submitting claims.

90832
99341
99342
99343
99344
99345
99347
99348
99349
99350
99490
99491
99497
99498
S0311
Z51.5

Coding (informational)

Informational CPT/HCPCS/ICD-10 codes referencedmixed

90832	30-minute psychotherapy session (16 to 37 minutes)
99341-99345	Home or residence visit (new patient, codes are time specific)
99347-99350	Home or residence visit (established patient, codes are time specific)
99490	Chronic care management services (first 20 minutes per calendar month) with required elements
99491	Chronic care management services provided personally by a physician (at least 30 minutes per calendar month)
99497	Advance Care planning — first 30 minutes (minimum of 16 minutes)
99498	Advance Care planning add-on for additional 30 minutes
S0311	Comprehensive management and care coordination for advanced illness, per calendar month
Z51.5	Encounter for palliative care (Secondary Code)

Codes listed in this policy are provided for informational purposes only and inclusion does not guarantee coverage. Providers should reference the most up-to-date professional coding guidance and current CPT/HCPCS/ICD-10 manuals prior to claim submission.

Background

Palliative care is patient- and family-centered care that addresses physical, psychological, emotional, and spiritual needs across serious and/or life-threatening illness and may be provided at any age and any stage of illness. It can be provided concurrently with curative treatment and does not require a six-month prognosis. Palliative care is distinct from hospice; a member 21 years of age or older may not be concurrently enrolled in hospice and palliative care. The policy specifies required minimum palliative services and eligibility criteria for adults and pediatric members.

Palliative Care definition

DefinitionComprehensive care addressing physical, psychological, emotional and spiritual needs of patients and families with serious and/or life-threatening illness; may be complementary to curative therapies.

Medicare Determinations

Determination Name	Type	Number	Effective Date	Notes
CMS definition of palliative care referenced
NCD

09/23 (policy effective date) per document; CMS definition cited in Background
CMS defines palliative care as patient- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering; referenced as the CMS definition in the policy background. Policy notes alignment with Medicare NCD/LCD review guidance.

Revision History

2009-09-23effective

Policy effective date (Policy developed based on APL, Date = 9/23).

9/23development

Policy developed and approved based on APL (All Plan Letter) on 9/23.

9/24revision

No update on 9/24 (revision log notes no update and no approval change).

9/25revisionLatest

No update on 9/25 (revision log notes no update and no approval change); last review date recorded as 9/25.