Clinical Policy: Hospice Services
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Defines medical necessity criteria, required documentation, severity-of-illness criteria, levels of hospice care, and not-medically-necessary conditions for hospice benefits for members/enrollees under the plan.
Revised forced vital capacity (FVC) threshold in II.B.3.a. from < 40% to < 30%.
Revised II.F.b.3 from '> 33% lean body mass' to 'loss of at least 10% lean body mass.'
Updated creatinine clearance threshold wording to '<15 ml/min' per LCD L34538 update.
Moved hospice description from background section into the policy description section and replaced all instances of 'member' with 'member/enrollee'.
Specific criteria edited across sections II.D.3.c, II.E.2.b, II.E.2.f, II.G, and II.I.2.a to add/replace brief clarifying phrasing (e.g., 'after bronchodilator (if able to obtain)').
Coverage and Medical Necessity Criteria
inv-01: Initial and diagnosis-specific severity criteria
Covered when ALL of the following are met
Only one level of care may be authorized per day; appropriate HCPCS/revenue codes must be billed.
Severity of illness categories
- Cancer: PPS or KPS <70%; dependence for at least two ADLs; and disease status such as metastatic cancer at presentation deferring therapy, progression to metastatic disease despite or deferring therapy, or specific cancers (brain, pancreatic, small cell lung).PPS/KPS <70%
- ALS: PPS or KPS <70%; dependence for at least two ADLs; and one of: impaired respiratory function not electing tracheostomy/invasive ventilation with FVC <30% (if available); rapid progression with ≥5% body weight loss; or rapid progression with life‑threatening complications (sepsis, recurrent aspiration, pyelonephritis, stage 3–4 decubiti).PPS/KPS <70%; FVC <30% (if available)
- Heart Disease: PPS or KPS <70%; dependence for at least two ADLs; and CHF symptomatic at rest (NYHA Class IV) with EF <20% (if available) and optimally treated or failed IV inotropes; or coronary disease with intractable angina not candidate for revascularization and failing medical therapy and not a transplant candidate.PPS/KPS <70%; EF <20%
- Pulmonary Disease: PPS or KPS <70%; dependence for at least two ADLs; disabling symptoms at rest or markedly diminished functional capacity with FEV1 <30% predicted; two ED visits in prior 6 months or one hospitalization in last year for pulmonary infection/respiratory failure requiring intubation or BiPAP; member declines intubation; or blood gas/oximetry criteria (PaO2 ≤55 mmHg or SaO2 ≤88% or PaCO2 ≥50 mmHg).FEV1 <30%; PaO2 ≤55 mmHg or SaO2 ≤88%
- Dementia: FAST stage 7 or beyond plus one or more medical complications in the past 12 months (aspiration pneumonia, pyelonephritis/UTI, septicemia, multiple stage 3–4 pressure ulcers, recurrent fever after antibiotics, >10% weight loss in 6 months, or albumin <2.5 g/dL).FAST ≥7; albumin <2.5 g/dL
- HIV: CD4 <25 cells/mm3 or viral load >100,000; PPS or KPS <50%; and at least one AIDS‑related condition (e.g., CNS lymphoma, wasting with ≥10% loss of lean body mass, MAC bacteremia, PML, refractory visceral Kaposi sarcoma, renal failure without dialysis, refractory cryptosporidium, refractory toxoplasmosis).CD4 <25 or viral load >100,000; PPS/KPS <50%
- Liver Disease: PPS or KPS <70%; dependence for at least two ADLs; end‑stage liver disease not on transplant list with laboratory or clinical indicators such as prolonged PT (>5 seconds) or INR >1.5 and albumin <2.5 g/dL plus one of recurrent variceal bleeding despite therapy, refractory ascites, spontaneous bacterial peritonitis, hepatorenal syndrome, or hepatic encephalopathy.INR >1.5; albumin <2.5 g/dL
- Renal Failure: PPS or KPS <70%; dependence for at least two ADLs; in renal failure and not receiving dialysis with either serum creatinine >8 mg/dL (>6 mg/dL if diabetes) or creatinine clearance <15 mL/min.Cr >8 mg/dL or CrCl <15 mL/min
- Stroke: PPS or KPS <40%; inadequate oral intake with weight loss >10% in 6 months or >7.5% in 3 months, or serum albumin <2.5 g/dL; or recurrent aspiration or dysphagia with declining tube feeding/hydration.PPS/KPS <40%
- Comatose with at least three specified findings on day three (e.g., abnormal brain stem responses, absent verbal response, absent withdrawal to painful stimuli, elevated creatinine >1.5 mg/dL).≥3 specified findings on day 3
- Non-Disease Specific Decline: Irreversible decline documented by baseline and follow‑up demonstrating progressive ADL dependence, KPS/PPS <70%, increasing ER visits or hospitalizations, worsening clinical signs/symptoms or labs, or progressive stage 3–4 pressure ulcers.KPS/PPS <70%
inv-02: Level of care criteria
Covered when ALL of the following are met for the specified level
inv-03: Subsequent requests and recertification
Continuation and changes to level of care
inv-04: Continuation and covered services
Covered when ALL of the following are met
Continuation statement aligns with recertification rules.
Services covered when the above coverage criteria are met.
The policy excludes hospice services when the member/enrollee’s primary diagnosis is debility or failure to thrive. These primary-diagnosis exclusions apply regardless of other clinical features and should be documented in the clinical record when used as the basis for a denial of hospice coverage.
Services provided during an acute inpatient stay for a diagnosis that is unrelated to the terminal illness are not covered as part of the hospice treatment plan. Additionally, hospice services are not covered for individuals who are no longer considered terminally ill; these services should be billed and adjudicated under the appropriate non-hospice benefit if applicable.
When state Medicaid coverage provisions conflict with this clinical policy, the state Medicaid coverage provisions take precedence. Providers should consult the applicable state Medicaid manual for any differing coverage rules that override the provisions of this policy.
Hospice services are not medically necessary when the member/enrollee is no longer considered terminally ill based on medical documentation review. Services are also not medically necessary when the primary diagnosis is debility or failure to thrive. These are explicit triggers for denial or discontinuation of hospice benefits and should be documented in the clinical record.
Services for individuals who are no longer considered terminally ill are not covered under the hospice treatment plan. In such cases, care that is unrelated to palliation of the terminal diagnosis should be pursued and billed under the appropriate alternative benefit or setting.
Codes, Performance Thresholds, and Physiologic Criteria
| T2042 | Routine Hospice Home Care |
| T2043 | Continuous Hospice Home Care |
| T2044 | Inpatient Respite Hospice Care |
| T2045 | General Inpatient, Short Term Hospice Care |
| 0651 | Routine Hospice Home Care (rev code) |
| 0652 | Continuous Hospice Home Care (rev code) |
| 0655 | Inpatient Respite Hospice Care (rev code) |
| 0656 | General Inpatient Short Term Hospice Care (rev code) |
| 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 |
| 0655 | Hospice inpatient respite care, per diem |
| 0656 | Hospice general inpatient, non-respite care, per diem |
| No codes listed |
Authorization, Documentation, and Provider Responsibilities
Authorization and billing: specify level, dates, and codes
Authorization is required for hospice services; requests must specify the level of care and exact dates of service. Only one level of care may be authorized per day, and the appropriate HCPCS (e.g., T2042–T2045) or revenue (e.g., 0651, 0652, 0655, 0656) code must be billed per applicable contract provisions.
- Specify level of care and dates on the authorization request.
- One level of care may be authorized for each day of hospice care.
- Bill the appropriate HCPCS or revenue code according to contract.
Pre-initiation authorization required
Authorization to provide hospice services must be obtained before hospice care is initiated; providers are responsible for obtaining this prior authorization.
- Obtain authorization prior to initiating hospice services for the member/enrollee.
Review Medicare NCDs/LCDs before applying criteria
For Medicare members/enrollees, review applicable National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Medicare Coverage Articles before applying this policy's criteria to ensure consistency with Medicare guidance.
- Refer to CMS (http://www.cms.gov) for current NCDs, LCDs, and Medicare Coverage Articles.
Subsequent authorizations and recertification requirements
Authorization is required for each change in the level of intensity of service; continuation of routine home care requires submission of a renewed hospice medical director certification for additional 90-day periods.
- Request authorization for any change to a higher intensity level (continuous, inpatient respite, general inpatient).
- Submit renewed hospice medical director certification to authorize additional 90-day routine home care periods.
Step therapy: none specified
No step therapy requirements are specified in this policy.
Required documentation for initial certification
Submit a hospice medical director’s written certification that identifies the terminal diagnosis, includes a statement that the member/enrollee’s life expectancy is six months or less if the terminal diagnosis follows its normal course, and provides clinical findings supporting that prognosis; also submit a hospice election statement signed by the member/enrollee or their healthcare proxy.
- Medical director written certification identifying terminal diagnosis and life-expectancy statement (≤ six months) with supporting clinical findings.
- Hospice election statement signed by the member/enrollee or healthcare proxy.
Provider responsibilities: eligibility, authorization, and notifications
Hospice providers must verify member/enrollee eligibility, obtain authorization before initiating hospice care, notify the health plan of any significant changes in status or treatment plans, and submit requests for each change in level of hospice service including discharge.
- Verify eligibility prior to providing hospice services.
- Obtain prior authorization before initiating hospice care.
- Notify the health plan of significant clinical/status changes or revisions to treatment plans and goals.
- Request authorization for each change in level of hospice service, including discharge.
Provider responsibility: exercise clinical judgment; policy is a guide
Providers are expected to exercise professional medical judgment and remain solely responsible for medical advice and treatment; this clinical policy is a guide to medical necessity and does not guarantee payment.
- Use the clinical policy as a medical necessity guide, not as a substitute for professional judgment.
- Providers retain responsibility for treatment decisions and are not guaranteed payment by policy alone.
Triggers for 'not medically necessary' determinations
Hospice services are not medically necessary when the primary diagnosis is debility or failure to thrive, when the member/enrollee is no longer considered terminally ill, when services are directed at curing the terminal condition (except for children under Medicaid/CHIP), or when the member/enrollee revokes election or is discharged from hospice.
- Primary diagnosis of debility or failure to thrive triggers non-coverage.
- Non-terminal status (no longer terminally ill) triggers non-coverage.
- Curative treatments/directives (except certain pediatric Medicaid/CHIP cases) are not covered under hospice.
Risk of denial if prior authorization not obtained
Failure to obtain authorization prior to initiation of hospice care risks denial of coverage.
- Obtain required prior authorization before starting hospice services to avoid claim denials.
Coverage decisions subject to member coverage documents and law
Coverage decisions and administration of benefits are subject to the terms, conditions, exclusions and limitations of the member's coverage documents and to applicable state and federal requirements; where state Medicaid provisions conflict with this clinical policy, the state Medicaid provisions take precedence.
- Verify member-specific coverage terms, exclusions, and limitations before relying on policy determinations.
- Follow state Medicaid rules when they conflict with this clinical policy.
Definitions and Levels of Care
Background and Scope
Hospice is multidisciplinary, end-of-life care focused on relieving pain and symptoms related to the terminal diagnosis for members/enrollees with a life expectancy of six months or less. The program emphasizes palliation rather than cure and uses interdisciplinary services—physician care, skilled nursing, aides, therapy, social services and counseling—directed at comfort and symptom management in the appropriate level of care.
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