Centene Hospice Services Prior Auth Policy Update

Coverage Criteria and Medical Necessity

Initial Hospice Medical Necessity

Covered when ALL of the following are met:

Initial Request: I. Required Documentation submitted; II. Member meets one of the listed severity of illness categories (A-K); III. Requested intensity of service appropriate for one of Routine, Continuous, Inpatient Respite, or General Inpatient levels.

See disease-specific criteria blocks for category II details.

II. Severity of Illness - Categories: Member meets criteria for at least one listed disease category: A. Cancer; B. ALS; C. Heart Disease; D. Pulmonary Disease; E. Dementia; F. HIV; G. Liver Failure; H. Acute or Chronic Renal Failure; I. Stroke; J. Coma; K. Non-Disease Specific Decline in Clinical Status.

Each category contains AND logic for performance status, ADL dependence and disease-specific findings (see respective disease-specific blocks).

Disease-specific: Cancer

Cancer — meets ALL of the following

Cancer: 1) Palliative Performance Scale (PPS) or Karnofsky Performance Status (KPS) score < 70%; 2) Dependence for at least two activities of daily living (ADLs) (e.g., ambulation, continence, transfers, dressing, feeding, bathing); 3) Disease status: a. Metastatic cancer at presentation deferring therapy; b. Progression to metastatic disease with decline despite therapy or deferring therapy; OR c. Brain, pancreatic, or small cell lung cancer.PPS/KPS <70%

Disease-specific: ALS

ALS — meets ALL of the following

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: a. Signs or symptoms of impaired respiratory function, not electing tracheostomy or invasive ventilation, with forced vital capacity (FVC) < 30% if results available; OR b. Rapid progression with critical nutritional impairment indicated by ≥5% weight loss (with or without tube feeding); OR c. Rapid progression with other life‑threatening complications (e.g., sepsis, recurrent aspiration, pyelonephritis, stage 3–4 decubiti).FVC <30% if available

Disease-specific: Non-Disease Specific Decline

K. Non-Disease Specific Decline in Clinical Status — meets ALL of the following

Non-Disease Specific Decline: 1) Irreversible decline demonstrated on baseline and follow-up determinations; and 2) Clinical deterioration in one or more of the following: a. Progressive dependence for ADLs; b. KPS or PPS score < 70%; c. Increasing frequency of ER visits or hospitalizations; d. Worsening clinical status, signs, symptoms or laboratory results (examples include recurrent infections, progressive weight loss, dysphagia, decreasing albumin, hypotension, ascites, edema, pleural or pericardial disease, decreased consciousness, intractable dyspnea, recurrent aspiration, abnormal labs); e. Progressive or stage 3–4 decubiti.KPS/PPS <70%

Consider presence of significant comorbidities when applying these criteria.

Intensity of Service (Level of Care) Criteria

Level of Care — choose one per day

Routine Hospice Home Care: Medically necessary when < eight hours of nursing care, which may be intermittent, is required in a 24‑hour period; bill HCPCS T2042 or revenue code 0651. Initial approval may be up to 90 days.<8 hours nursing/24h

Continuous Hospice Home Care: Medically necessary when ≥ eight hours of nursing care are required in a 24‑hour period (period begins and ends at midnight); bill HCPCS T2043 or revenue code 0652. Up to five days may be approved with ongoing concurrent review for additional days requested.>=8 hours nursing/24h

At least 50% of total care must be provided by a nurse when supplemented by aides; care must be predominantly nursing rather than personal care.

Inpatient Respite Hospice Care: Short‑term inpatient care to relieve primary caregivers for no more than five consecutive days per episode; bill HCPCS T2044 or revenue code 0655. Respite is short‑term inpatient care and not residential or custodial care.

Covered Services

Covered when hospice coverage criteria are met and included in the hospice treatment plan

Covered Hospice Services: When coverage criteria are met, services that may be included in the hospice treatment plan include: physician services; appropriate skilled nursing services; home health aide services; physical and/or occupational therapy; speech therapy for dysphagia/feeding; medical social services; counseling services (e.g., dietary, bereavement); short‑term inpatient care; prescription drugs necessary for palliation and management of the terminal illness and related conditions; and consumable medical supplies used by the hospice team.

Levels of Care

Levels of hospice care and setting-specific requirements

Continuous Hospice Home Care: Primarily skilled nursing care at home during brief crisis periods to palliate or manage acute symptoms; must provide a minimum of eight 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 personal care; may be supplemented by home health aide or homemaker services.8 hours per 24‑hr; >=50% nursing

Not intended as respite or an alternative to paid caregivers or placement.

Inpatient Respite Hospice Care: Short‑term inpatient care in an approved facility, hospital or nursing home for no more than five consecutive days per episode to relieve primary caregivers.<=5 consecutive days

Primary caregiver is the individual designated by the member who is responsible for 24‑hour care; caregiver need not elect hospice if hospice team determines member safe at home alone.

Services are considered not medically necessary when the member's primary diagnosis is debility or unspecified debility or failure to thrive. These conditions, when listed as the primary diagnosis, meet the policy's explicit exclusion for hospice benefit eligibility and are grounds for denial of hospice services.

Hospice does not cover services provided during an acute inpatient stay for a diagnosis unrelated to the member's terminal illness. Coverage also excludes services for individuals who are no longer considered terminally ill; such care is not part of the hospice benefit and should be billed under the appropriate non-hospice benefit.

Coverage and benefit administration are governed by the member's contractual coverage documents (for example, the evidence of coverage, certificate of coverage, policy or contract of insurance) and applicable state and federal requirements. Providers should follow those documents and Health Plan administrative policies when determining coverage for hospice services.

Services are not medically necessary when the member is no longer considered terminally ill as documented in the medical record. Other situations rendering hospice services not medically necessary include when the member revokes hospice election, is discharged from hospice, or when the primary diagnosis is debility/unspecified debility or failure to thrive.

Interventions intended to cure the terminal condition are excluded from hospice coverage. Such curative services, supplies, procedures, or medications are not covered under the hospice treatment plan, with the exception that children enrolled in Medicaid or CHIP receiving concurrent curative care may receive such services concurrent with hospice.

Coding, Performance Scales, and Clinical Thresholds

Covered HCPCS and revenue codesmixedCovered

T2042	Routine Hospice Home Care
T2043	Continuous Hospice Home Care
T2044	Inpatient Respite Hospice Care
T2045	General Inpatient, Short Term (non-respite) Hospice Care
0651	Revenue code — Routine Hospice Home Care
0652	Revenue code — Continuous Hospice Home Care
0655	Revenue code — Inpatient Respite Hospice Care
0656	Revenue code — General Inpatient, Short Term Hospice Care

Covered/Informational hospice codesmixed

T2042	Hospice routine home care; per diem.
T2043	Hospice continuous home care; per hour.
T2044	Hospice inpatient respite care, per diem.
T2045	Hospice general inpatient care; per diem.
T2046	Hospice long-term care, room and board only; per diem.
G0337	Hospice evaluation and counseling services, pre-election
0651	Hospice routine home care; per diem.
0652	Hospice continuous home care, per 15 minutes

Covered/Informational hospice codesmixed

T2042	Hospice routine home care; per diem.
T2043	Hospice continuous home care; per hour.
T2044	Hospice inpatient respite care, per diem.
T2045	Hospice general inpatient care; per diem.
T2046	Hospice long-term care, room and board only; per diem.
G0337	Hospice evaluation and counseling services, pre-election
0651	Hospice routine home care; per diem.
0652	Hospice continuous home care, per 15 minutes

Revenue codes / modifiersmixed

0655	Hospice inpatient respite care, per diem.
0656	Hospice general inpatient, non-respite care, per diem.
0658	Hospice room and board, nursing facility.
0657	Hospice charges for services furnished to patients by physician or nurse practitioner employees, or physicians or nurse practitioners receiving compensation from the hospice.
GV (modifier)	Physician services performed by a nurse practitioner require the addition of the modifier GV with revenue code 0657.

Performance scales and physiologic thresholds

Common performance thresholdPPS or KPS score < 70% for most disease categories

ALS-specific physiologic thresholdForced vital capacity (FVC) < 30% (if results available)

CHF-specific physiologic thresholdEjection fraction (EF) < 20% (if results available) with NYHA Class IV symptoms

Pulmonary disease thresholdFEV1 < 30% or PaO2 ≤ 55 mmHg or SaO2 ≤ 88% or PaCO2 ≥ 50 mmHg

Renal failure thresholdsSerum creatinine > 8 mg/dl (or >6 if diabetes) or creatinine clearance < 15 ml/min

Nutritional / laboratory thresholdsAlbumin < 2.5 g/dl for select conditions (e.g., liver disease, stroke criteria)

Provider Requirements, Authorization, and Documentation

Prior Authorization

Authorization and billing codes required

Authorization is required for the level of care and dates requested. Only one level of care may be authorized for each day of hospice care provided to an eligible member/enrollee. The appropriate HCPCS or revenue (rev) code must be billed according to applicable contract provisions.

Specify level of care and dates when requesting authorization
Only one level of care authorized per day (e.g., Routine T2042/0651; Continuous T2043/0652; Inpatient Respite T2044/0655; General Inpatient T2045/0656)

Prior Authorization

Prior Authorization Required

Authorization must be obtained before hospice care is initiated. Failing to obtain prior authorization may risk denial of payment.

Obtain authorization prior to initiation of services
Request authorization for each change in level of hospice service

Background and Scope

Hospice is a multidisciplinary, end-of-life program focused on relieving pain and symptoms related to a terminal diagnosis for members with an expected life expectancy of six months or less if the illness runs its normal course. Eligibility and medical necessity decisions rely on documented clinical findings, performance status measures, functional decline and other criteria as specified in this policy and must be applied in the context of the member's coverage documents and applicable regulatory requirements.

Definitions and Levels of Care

Routine Hospice Home Care

DefinitionCare provided in the member's home related to the terminal diagnosis and plan of care; may be in a private residence, hospice residential facility, nursing facility, or adult care home

Nursing time allowanceMay include up to 8 hours of skilled nursing care in a 24-hour period

PurposeServices relate to palliation and management of the terminal illness and are provided under the hospice plan of care

Continuous Hospice Home Care

DefinitionPrimarily skilled nursing care at home during brief crisis periods to palliate or manage acute medical symptoms

Minimum nursing hoursRequires at least eight hours of nursing care in a 24-hour period (begins and ends at midnight)