Currentsierra health and lifePolicy N/A

Palliative Care (Home & Hospice) Coverage Criteria

Defines clinical admission criteria, provider roles, services, benefits, and referral process for palliative care delivered in home, custodial residences, or contracted inpatient facilities for Sierra Health and Life members.

Policy Summary

Payersierra health and life

PolicyPalliative Care (Home & Hospice) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPlace a referral call to a contracted palliative care agency listed in the plan directory to initiate services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12.7policy section identifier

4+ER/hospital visits trigger

12-24 moprognostic timeframe

24/7individualized care availability

Coverage Criteria for Palliative Care

Admission Criteria

Covered when ANY of the following admission criteria are met (clinician-documented):

Admission Criteria (any): Primary medical provider indicates 12-24 month probability of death; Frequent ER or hospital visits (4 or more) due to serious illness in last 12 months; Progression of illness over past six (6) months; Stage 3 or 4 cancer, or curative cancer with potentially toxic treatments; New diagnosis of life limiting illness; Unintentional and consistent weight loss over six (6) months; Multiple chronic illnesses or any single chronic illness which remains symptomatic or limits function despite maximal treatment; Dementia causing inability to perform two (2) or more activities of daily living; Continued oxygen dependence, shortness of breath, or adverse cardiac symptoms brought on by exertion despite continued treatment; Patient is not a candidate for curative therapy or patient/family request for treatment with low probability for success; Patient, family or physician uncertainty regarding appropriateness, usefulness, or desirability of available treatment options; Patient/family need assistance with advanced care planning.See individual bullet criteria

Referrals may come from the physician, patient, family, friends, social workers or clergy.

No explicit exclusions are listed in this policy document.

The policy implies that palliative services are covered only when a clinician documents that one or more of the listed admission criteria are met; therefore, failure to meet those admission criteria (for example, not meeting the referenced prognosis, visit frequency, disease progression, functional limitations, or other listed indicators) indicates the services would not be indicated under this coverage guidance.

Policy Summary

Payersierra health and life

PolicyPalliative Care (Home & Hospice) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionPlace a referral call to a contracted palliative care agency listed in the plan directory to initiate services.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Referral, Documentation, and Operational Requirements

Prior Authorization

Referral/Initiation Requirement — Call to Contracted Agency

Place a call to a contracted palliative care agency (found in our Health Plan of Nevada online directories). Individualized care is available 24-hours-a-day, 7-days-a-week.

Referrals may be initiated by physician, patient, family, friends, social workers, or clergy.

Documentation Required

Required Clinical Documentation

Provider must document clinical indicators supporting admission including prognosis (12–24 month probability of death), frequency of ER/hospital visits (e.g., 4+ in last 12 months), recent disease progression (past 6 months), stage and treatment status for cancer, new life‑limiting diagnoses, unintentional weight loss over 6 months, limitations from multiple or severe chronic illnesses, dementia causing inability to perform ≥2 ADLs, ongoing oxygen dependence or exertional cardiopulmonary symptoms despite treatment, candidacy for curative therapy, uncertainty about appropriateness of treatments, and need for advance care planning.

Document prognosis timeframe (12–24 months) and evidence supporting it.
Record number and dates of recent ER/hospital visits and documentation of disease progression within 6 months.
Document functional status (ADLs), oxygen dependence, symptom burden, and impact of treatment limitations.
Include notes on patient/family goals, advance care planning discussions, and source of referral.

Denial Risk

Admission Criteria Nonconformance — Denial Risk

If the patient does not meet the listed admission criteria (e.g., prognosis, visit frequency, disease progression, functional limitations), services may be considered not indicated and could be denied as non‑covered. Failure to provide the required supporting documentation may result in noncoverage.

Absence of documentation for admission criteria may lead to claim denial or referral return for additional information.

Definitions

inv-11: Palliative Care definition

DefinitionAn additional layer of support for patients facing life-changing illness to help manage symptoms, stress, and goals of care

Service settingDeliverable in the home, custodial residence, or contracted inpatient facilities depending on patient needs

Care approachSupports patients and families while patients may continue treatments that could cure or heal

inv-12: Admission Criteria definition

SummaryClinical and utilization conditions used to identify candidates for palliative care, including prognosis, frequent ER/hospital visits, progression of illness, advanced cancer stages, weight loss, chronic disease burden, dementia with ADL impairment, oxygen dependence, unsuitability for curative therapy, uncertainty about treatment options, and need for advanced care planning

Examples of specific criteria12-24 month prognosis; >=4 ER/hospital visits in past 12 months; progression of illness over past 6 months; Stage 3 or 4 cancer; unintentional weight loss over 6 months; inability to perform 2+ ADLs

Referral sourcesReferrals may be initiated by physician, patient, family, friends, social workers, or clergy

OpenPayer

Palliative Care (Home & Hospice) Coverage Criteria

Coverage Criteria for Palliative Care

Key Utilization Indicators

Referral, Documentation, and Operational Requirements

Background on Palliative Care

Definitions