Medicare Eligibility Criteria: Indicators for Referral

Wellmark, Inc.,
Last Modified: June 1, 1998

Share article


Pulmonary Disease

ALL of the following required:
Severe chronic lung disease with:
Disabling dyspnea at rest, decreased functional capacity and poor bronchodilator response (FEV1 after bronchodilator < 30% predicted, if available)
Progression of end-stage disease with:
Increased ER or MD home visits OR
Hospitalization for pulmonary infections
Hypoxemia at rest while on oxygen (p02 55; 02 sat 88 on 02) or Hypercapnea (pC02 50)
Cor Pulmonale/right heart failure


Liver Disease

PT > 5 seconds over control (INR > 1.5) OR
Serum albumin < 2.5 gm/dl
AND ONE of the following:
Ascites despite diuretics or patient noncompliant
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatic encephalopathy
Recurrent variceal bleeding


Heart Disease

Class IV CHF, symptomatic at rest
(Ejection Fraction < 20%) (if available)
AND
Optimal diuretic and vasodilator therapy, as tolerated OR
Refractory angina resistant to medical therapy; Not a revascularization candidate or declines revascularization


Renal Disease

Not seeking dialysis or renal transplant
AND
Cr Cl < 10 cc/m (< 15 cc/m diabetics)
With CHF: Cr Cl < 15 cc/min (20 cc/m in diabetics)
OR
Cr > 8 mg/dl (> 6 mg/dl diabetics)


Stroke, Acute Phase

Coma or persistent vegetative state for 3 days OR
In post-anoxic stroke, 3 days post-anoxic event, coma or severe obtundation with severe myoclonus OR
Dysphagia preventing adequate intake w/o artificial feeding or hydration


Stroke, Chronic Phase

Poor functional status (KPS 40) OR
Dementia (with ALL of the following):
FAST score > 7
Unable to ambulate, dress, bathe without assistance
Urinary and fecal incontinence
Speech limited to 6 intelligible words
OR Poor nutritional status/weight loss
> 10% in past 6 months or serum albumin > 2.5 gm/dl


Coma

Coma or Persistent Vegetative State on day > 3, AND ANY 3 of the following:
Abnormal brain stem response
Absent verbal response
Absent withdrawal response to pain
Cr > 1.5 mg/dL


ALS (Lou Gehrig's Disease)

Patients must meet one of the following three criteria:
Critically impaired breathing capacity as demonstrated by ALL of the following occurring within the the 12 months preceding initial hospice certification:
Vital capacity < 30% of normal
Dyspnea at rest
Requiring supplemental 02 at rest
Patient declines artificial ventilation; external ventilation used for comfort only
Rapid Progression of ALS AND critical nutritional impairment
Rapid progression of ALS as demonstrated by ALL of the following occurring within the 12 months preceding initial hospice certification.
Progression from:
Independent ambulation to wheelchair to bedbound
Normal to barely or unintelligible speech
Normal to pureed diet
Independent ADLs to needing major assistance
Critical nutritional impairment as demonstrated by ALL of the following occurring within the 12 months preceding initial hospice certification:
Oral intake of nutrients and fluids insufficient to sustain life
Continuing weight loss
Dehydration or hypovolemia
Absence of artificial feeding methods, sufficient to sustain life, but not for relieving hunger
Rapid progression of ALS AND life-threatening complications
Rapid progression of ALS (see above)
Life-threatening complications as demonstrated by ONE of the following occurring within the 12 months preceding initial hospice certification:
Recurrent aspiration pneumonia (with our without tube feeding)
Upper urinary tract infections (e.g. pyelonephritis)
Sepsis
Recurrent fever after antibiotic therapy
Stage 3 or 4 decubitus ulcer(s)


AIDS (HIV Disease)

CD4 < 25 cells/mcl
OR
Viral load > 100,000 copies/ml
AND ONE of the following:
Wasting (> 33% loss of lean body mass) despite meds
Cryptosporidium
CNS or systemic lymphoma
Unresponsive MAC bacteremia or toxoplasmosis or treatment refused
PML
Visceral KS, unresponsive
Karnovsky Perf Status (KPS) 50 (see Karnofsky Scale on page 4)
Renal failure without dialysis


Decline in Health Status

Patients with decline in health status must show decline in the clinical variables listed below:
Progression of disease as documented by symptoms, signs and test results.
Decline in Karnofsky Performance Status or Palliative Performance Score/Adapted Karnofsky (see Karnofsky Scale on page 4)
Weight Loss; decreased anthropormorphic measurements (med-arm circumference, abdominal girth) not due to reversible causes such as depression or use of diuretics; decreasing serum albumin or cholesterol
Dependence on assistance for two or more activities of daily living (ADLs)
Feeding
Ambulation
Continence
Transfer
Bathing
Dressing
Dysphagia leading to inadequate nutritional intake (document by, for example, a trend established by comparing changes in food portion consumption)
Recurrent aspiration
Decline in systolic blood pressure to < 90 systolic or progressive postural hypertension
Increasing emergency room visits or hospitalizations related to the hospice primary diagnosis
Decline in Functional Assessment Staging (FAST) for dementia (see FAST scale on page 4)
Progressive Stage 3-4 pressure ulcers in spite of optimal care


Failure to Thrive

For patients not meeting any other criteria, including Decline in Health Status:
Decubiti
Weight < 80% ideal weight
No feeding tube
Not eating
Frequent infections
Serum albumin < 2.5 gm/dl
Cholesterol < 156 mg/dl
Hematocrit < 41 mg/dl


Dementia

Stage 7 or beyond according to FAST scale (see FAST scale on page 4)
AND
Unable to walk, dress or bathe without assistance
AND
Urinary and fecal incontinence
AND
Unable to speak or communicate meaningfully, or using 6 meaningful words
AND ONE of the following complications within the past year:
Aspiration pneumonia
Pyelonephritis or other UTI infections
Septicemia
Multiple stage 3-4 decubitus ulcers
Recurrent fevers after antibiotics
Inability to maintain sufficient fluid and calorie intake
Weight loss > 10% despite tube feeds or albumin < 2.5 g/dl


News
Use of androgen-deprivation therapy for non-evidence-based indications fell from 2003 to 2005

Nov 4, 2010 - Implementation of the Medicare Modernization Act, which led to reduced reimbursement for androgen-deprivation therapy for prostate cancer, appears to have substantially reduced the rate at which the therapy is used for inappropriate indications, according to research published in the Nov. 4 issue of the New England Journal of Medicine.



Blogs and Web Chats

OncoLink Blogs give our readers a chance to react to and comment on key cancer news topics and provides a forum for OncoLink Experts and readers to share opinions and learn from each other.




OncoLink OncoPilot

Facing a new cancer diagnosis or changing the course of your current treatment? Let our cancer nurses help you through!

Learn More