CurrenthealthnetnationalPolicy N/A

Hospice eligibility: general criteria for coverage

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Defines general clinical criteria and disease-specific examples used to determine hospice appropriateness for members with terminal illnesses; applies to providers seeking hospice admission or certification under Health Net National.

Policy Summary

Payerhealthnetnational

PolicyHospice eligibility: general criteria for coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument terminal prognosis (~6 months or less), evidence of incurable or progressive disease as applicable, and patient/family election of palliative-focused care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~6 monthsPrognosis threshold

10%+Weight loss threshold

3+ER visits marker

Hospice Coverage Criteria

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CurrenthealthnetnationalPolicy N/A

Hospice eligibility: general criteria for coverage

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Policy Summary

Payerhealthnetnational

PolicyHospice eligibility: general criteria for coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument terminal prognosis (~6 months or less), evidence of incurable or progressive disease as applicable, and patient/family election of palliative-focused care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~6 monthsPrognosis threshold

10%+Weight loss threshold

3+ER visits marker

Hospice Coverage Criteria

Core eligibility: Patient's illness is incurable AND has a declining functional status; the patient/family have been informed that the patient's condition is terminal; the patient/family have elected treatment directed toward palliative care; quality of life is currently unacceptable to the patient/family; prognosis is for a life expectancy of approximately 6 months or less if the disease runs its normal course.

based on general criteria

Observable clinical deterioration (supporting examples): Unintentional weight loss - more than 10% over last 3-6 months OR decreased appetite/nutritional intake related to the terminal process OR decreased activity tolerance with restriction in activities of daily living OR decreased cognitive abilities OR multiple emergency room visits (3 or more) in last 3-6 months.

examples that support declining functional status

Disease-Specific End-Stage Examples

Consider hospice when disease-specific end-stage features are present (examples listed); these support the core eligibility criteria

Cardiopulmonary end-stage features: Disabling dyspnea at rest or with minimal exertion poorly responsive to bronchodilators; recurrent congestive heart failure (NYHA Class IV) on optimal diuretic therapy; presence of corpulmonale; recurrent pulmonary infections and/or respiratory failure; chronic hypoxemia (less than 90% at rest on supplemental oxygen); chronic hypercapnia (pCO2 more than 50 mm Hg); intractable angina; resting tachycardia (more than 100/min) or symptomatic arrhythmias resistant to therapy.

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Neurologic end-stage features: Severe Alzheimer's disease, stroke, Parkinson's disease, ALS, or traumatic brain injury indicating end-stage neurologic disease.

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Renal end-stage features: Chronic dialysis patient or dialysis candidate who has chosen to refuse dialysis.

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Liver end-stage features: Severe ascites, esophageal varices, peripheral edema, jaundice, or hepatic encephalopathy/coma.

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AIDS end-stage features: Severe weight loss, recurrent infections, and increased debilitation requiring supportive care; patient has been on therapy and is refusing therapy or has shown resistance to available medications.

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Malignant disease features: Documented tissue diagnosis of malignant or metastatic disease with an incurable diagnosis where treatment is regarded as most likely to be futile; evidence of progressive cancer where treatment is felt to be futile; or a patient with curable disease who refuses treatment or cannot tolerate it, or where treatment is for palliative reasons.

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The policy does not list any conditions as explicit exclusions. There is no separate exclusions list; instead, appropriateness is determined by whether the general hospice eligibility criteria and the disease-specific end‑stage examples are met. For malignant disease the document provides supporting examples (for instance, documented tissue diagnosis of metastatic or incurable cancer or progressive cancer where treatment is futile) but does not state these or any other diagnoses are categorically excluded from hospice coverage.

This document does not identify any services or diagnoses as explicitly 'not medically necessary.' Coverage determinations are based on whether the general hospice eligibility criteria are satisfied — for example, incurable illness with declining function, documented terminal status, election of palliative care, and an approximate life expectancy of 6 months if the disease follows its usual course — rather than on a list of not‑medically‑necessary items.

Clinical Markers and Coding-relevant Findings

Unintentional weight loss — threshold

DefinitionUnintentional weight loss >10% over the last 3–6 months

Clinical relevanceListed as an observable sign of declining functional status supporting hospice eligibility

TimeframeMeasured over the preceding 3–6 months

Use in assessmentConsider with other deterioration markers (decreased appetite, ADL decline, frequent ER visits)

Chronic hypoxemia — threshold

DefinitionChronic hypoxemia: oxygen saturation <90% at rest while on supplemental oxygen

Clinical contextListed among cardiopulmonary end-stage features supporting hospice consideration

Associated findingsOften occurs with disabling dyspnea, recurrent infections, or respiratory failure

Chronic hypercapnia — threshold

DefinitionChronic hypercapnia: arterial pCO2 >50 mm Hg

Clinical contextIncluded as an end-stage cardiopulmonary feature supporting hospice eligibility

Associated findingsMay accompany respiratory failure or chronic ventilatory insufficiency

Documentation and Provider Requirements

Prior Authorization

Hospice eligibility documentation

Hospice eligibility requires documentation that the patient’s illness is incurable with declining functional status, the patient/family have been informed the condition is terminal (prognosis approximately 6 months or less), and the patient/family have elected treatment directed toward palliative care.

Document incurable or progressive disease and declining function.
Document that patient/family were informed the condition is terminal (≈6 months if disease runs its normal course).
Document election of palliative-focused treatment by the patient/family.

Step Therapy

Step therapy — not applicable

No step therapy requirements apply for hospice admission under this policy.

Documentation Required

Required clinical documentation

Required clinical documentation must show an incurable illness with declining functional status, that the patient/family have been informed the condition is terminal, and that the patient/family elected palliative goals; for malignant disease include a documented tissue diagnosis and evidence that disease is progressive or that curative treatment is refused or futile.

For malignant disease: include documented tissue diagnosis and evidence disease is progressive or curative treatment is refused/cannot be tolerated or is futile.

Denial Risk

Documentation-based denial risk

A denial may be issued if documentation does not demonstrate a prognosis of approximately 6 months or less or does not document that the patient/family elected palliative-focused treatment after being informed the condition is terminal.

Absence of documentation showing terminal prognosis (≈6 months) and/or lack of documented election of palliative care increases denial risk.

Background

Hospice care is intended for patients with terminal illnesses who have limited life expectancy and who prioritize comfort and quality of life over curative treatment. Eligibility in this policy requires documentation that the illness is incurable with declining functional status, the patient/family have been informed the condition is terminal, and the patient/family have elected treatment directed toward palliative goals. The policy uses a prognosis threshold of approximately 6 months or less if the disease runs its normal course as the key prognostic cutoff for hospice consideration.

Key Definitions

Terminal / prognosis threshold

DefinitionPrognosis for a life expectancy of approximately 6 months or less if the disease runs its normal course.

Role in eligibilityCore component of hospice eligibility — must be documented to support admission/certification

Assessment noteDetermination based on clinical judgment and disease trajectory as documented in the medical record

Election of palliative care

DefinitionPatient/family decision to direct treatment toward palliative goals and acknowledgement that the condition is terminal.

Documentation requirementMust be clearly recorded in the medical record to demonstrate election of hospice-focused care

ImplicationAbsence of documented election may lead to denial of hospice coverage

Policy Summary

Payerhealthnetnational

PolicyHospice eligibility: general criteria for coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument terminal prognosis (~6 months or less), evidence of incurable or progressive disease as applicable, and patient/family election of palliative-focused care.

SourceLink

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