Cigna Hospice Care Coverage Update

Coverage Criteria for Hospice Services

Hospice medical necessity

Hospice care services are considered medically necessary when ALL of the following criteria are met:

Eligibility requirements: The individual is terminally ill and expected to live twelve months or less.12 months or less

supported by physician certification

Treatment intent: Potentially curative treatment for the terminal illness may be part of the prescribed plan of care.

policy allows concurrent palliative and some curative/life-prolonging treatments

Consent: The individual or appointed designee has formally consented to hospice care directed mostly toward palliative care and symptom management.

Provider accreditation: Hospice services are provided by a certified/accredited hospice agency with care available 24 hours per day, seven days per week.

Considered Medically Necessary (by code groups)

Considered Medically Necessary when criteria in the applicable policy statements listed above are met:

Medically necessary coding: Services billed with the listed CPT/HCPCS/QC codes are considered medically necessary when the applicable policy statements' clinical criteria are satisfied.

Codes are time-, location-, and service-specific and require supporting clinical documentation per the applicable policy statements (examples include 99497-99498, G0151-G0153, G0155-G0156, G0162, G0299-G0300, G0337, G0493-G0496, Q5001-Q5010, S0255, S0257, S9126, 0651-0659).

The policy identifies specific services that are not considered medically necessary or are outside the scope of hospice coverage. These include services provided to an individual who is no longer considered terminally ill, interventions that are provided primarily to assist with activities of daily living (ADLs) such as personal hygiene, feeding, dressing, or transfers, and items intended for general nutritional support (including nutritional supplements, vitamins, and minerals) or non‑prescription drugs. Also excluded are medical supplies unrelated to the palliative care being provided and any services for which benefits are available under another coverage category. Claims for such items or services should not be submitted as hospice care because they do not meet the policy’s definition of medically necessary hospice services.

Respite care provided specifically for hospice and billed with HCPCS code S9125 (respite care, in the home, per diem) is explicitly excluded and not covered by this policy when the respite is specific to hospice. Providers should not bill S9125 for hospice‑specific respite services under Cigna‑administered plans.

Services that are primarily intended to support activities of daily living (ADLs) rather than to provide palliative medical care are considered not medically necessary as hospice services. Examples include help with bathing, feeding, dressing, toileting, or transfers. In addition, non‑prescription items and supplies used for general support—such as over‑the‑counter drugs, vitamins, minerals, and nutritional supplements—or medical supplies that are not directly related to the palliative plan of care are not considered hospice‑covered items and are not medically necessary under this policy.

Code Listings and Clinical Thresholds

Considered medically necessary codesmixedCovered

99497	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
99498	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure).
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.

Considered Medically Necessary - advance care planning and therapy time-based codesCPTCovered

99497	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate.
99498	Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure).
G0151	Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes.
G0152	Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes.
G0153	Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes.

Considered Medically Necessary - skilled nursing, social work, aides, evaluation/counselingHCPCSCovered

G0155	Services of clinical social worker in home health or hospice setting, each 15 minutes.
G0156	Services of home health/hospice aide in home health or hospice settings, each 15 minutes.
G0162	Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential non-skilled care achieve its purpose in the home health or hospice setting).
G0299	Direct skilled nursing services of a registered nurse (RN) in the home health or hospice setting, each 15 minutes.
G0300	Direct skilled nursing services of a licensed practical nurse (LPN) in the home health or hospice setting, each 15 minutes.
G0337	Hospice evaluation and counseling services, pre-election.
G0493	Skilled services of a registered nurse (RN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting).
G0494	Skilled services of a licensed practical nurse (LPN) for the observation and assessment of the patient's condition, each 15 minutes (the change in the patient's condition requires skilled nursing personnel to identify and evaluate the patient's need for possible modification of treatment in the home health or hospice setting).
G0495	Skilled services of a registered nurse (RN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.
G0496	Skilled services of a licensed practical nurse (LPN), in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes.

Considered Medically Necessary - place-of-service, referral, per diem, and hospice revenue codesmixedCovered

Q5001	Hospice or home health care provided in patient's home/residence.
Q5002	Hospice or home health care provided in assisted living facility.
Q5003	Hospice care provided in nursing long-term care facility (LTC) or nonskilled nursing facility (NF).
Q5004	Hospice care provided in skilled nursing facility (SNF).
Q5005	Hospice care provided in inpatient hospital.
Q5006	Hospice care provided in inpatient hospice facility.
Q5007	Hospice care provided in long-term care facility.
Q5008	Hospice care provided in inpatient psychiatric facility.
Q5009	Hospice or home health care provided in place not otherwise specified (NOS).
Q5010	Hospice home care provided in a hospice facility.

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Excluded and Not CoveredHCPCSNot Covered

S9125

Respite care, in the home, per diem

Life expectancy threshold — hospice eligibility timeframe

Life expectancy thresholdPatient is considered terminally ill with a life expectancy of 12 months or less (physician certification required).

Recertification if survival >12 monthsIf patient lives longer than 12 months, physician must recertify terminal status to continue hospice benefits.

Basis for certificationPhysician certification is generally based on clinical judgment and should be supported by documentation of prognostic indicators (e.g., weight loss, declining function).

Routine home care nursing hours — threshold for routine home care

Routine home care nursing hoursTypically requires fewer than 8 hours of primarily nursing care per 24-hour period; nursing need not be continuous.

Provider Requirements and Authorization

Prior Authorization

Prior Authorization / Code applicability

Prior authorization and code applicability: Hospice services are subject to the terms, conditions, and limitations of the member's benefit plan. When hospice benefits are available, providers must follow plan requirements and submit services using the appropriate covered diagnosis and procedure codes. Claims submitted without covered diagnosis or procedure codes listed in this policy will be denied. Prior authorization (utilization review) may be required per the member's plan — verify benefit availability and any authorization requirements with the applicable benefit plan document and payer before rendering services.

Claims must include covered diagnosis/procedure codes listed in this policy.
Verify prior authorization requirements and benefit availability with the member's plan document.
When billing, use the most appropriate codes as of the date of service.

Definitions and Program Terms

Hospice care program — definition of hospice program and scope

DefinitionA hospice care program is a coordinated program of palliative and supportive services providing physical, psychological, social, and spiritual care for dying persons, their families, and other loved ones.

Scope of servicesServices generally include nursing care, physicians' services, nurse practitioner services, medical social services and other supportive services focused on comfort and symptom management.

SettingsServices are provided in the home and inpatient settings (e.g., hospital, freestanding hospice facility, nursing home) and are available to patients of all ages.

Levels of hospice care — routine, continuous, inpatient respite, general inpatient care

Levels of care (4)Routine home care, Continuous home care, Inpatient respite care, and General inpatient care.

Background

This policy describes hospice as a palliative approach focused on comfort and symptom management rather than cure, delivered to individuals who are terminally ill and appropriate for hospice services. Hospice care is interdisciplinary and addresses physical, psychological, social, and spiritual needs; it may be provided in the home or in inpatient settings. The policy’s exclusions emphasize that hospice benefits are limited to services that support palliative care goals and do not extend to routine ADL assistance, nutritional supplements, non‑prescription items, or supplies unrelated to symptom management.

OpenPayer

Hospice Care Services Coverage Criteria

Coverage Criteria for Hospice Services

Code Listings and Clinical Thresholds

Provider Requirements and Authorization

Definitions and Program Terms

Background