Local Coverage Determination (LCD)

Hospice - HIV Disease

L34566

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B and HHH MAC	11004 - HHH MAC	J - M	Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee Texas

LCD Information

Document Information

LCD ID
L34566

LCD Title
Hospice - HIV Disease

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 11/04/2021

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(1)(6) consitutes personal comfort items (except, in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1862(a)(1)(9) addresses expenses for custodial care (except, in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1812(a)(4) states in lieu of certain benefits, hospice care with respect to the individual during up to 2 periods of 90 days each and an unlimited number of subsequent periods of 60 days with respect to which the individual makes an election.

Title XVIII of the Social Security Act, §1813(a)(4)(A)(i) addresses drugs and biologicals provided in a hospice program.

Title XVIII of the Social Security Act, §1814(a)(7)(A)(i) addresses certifying the patient for hospice.

42 CFR, Part 418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60 Certification and Recertification by Physicians for Hospice Care

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20 Certification and Election Requirements, §20.1 Timing and Content of Certification, §20.2 Election, Revocation, and Discharge, §20.2.1 Hospice Election, §20.2.1.1 Hospice Election Statement, §20.2.1.2 Hospice Election Statement Addendum, §20.2.1.3 Hospice Notice of Election, §20.2.2 Hospice Revocation, §20.2.3 Hospice Discharge, §20.2.4 Hospice Notice of Termination or Revocation, §40 Benefit Coverage, §40.1 Covered Services, §40.1.1 Nursing Care, §40.1.2 Medical Social Services, §40.1.3 Physician's Services, §40.1.3.1 Attending Physician Services, §40.1.3.2 Nurse Practitioners as Attending Physicians, §40.1.3.3 Physician Assistants as Attending Physicians, §40.1.4 Counseling Services, §40.1.5 Short-Term Inpatient Care, §40.1.6 Medical Appliances and Supplies, §40.1.7 Hospice Aide and Homemaker Services, §40.1.8 Physical Therapy, Occupational Therapy, and Speech-Language Pathology, §40.1.9 Other Items and Services, §40.2 Special Services, §40.2.1 Continuous Home Care (CHC), §40.2.2 Respite Care, §40.2.3 Bereavement Counseling, §40.2.4 Special Modalities, §40.3 Contracting With Physicians, §40.4 Core Services, §40.4.1 Contracting for Core Services, §40.4.1.1 Contracting for Highly Specialized Nursing Services, §40.4.2 Waiver for Certain Core Staffing Requirements, §40.4.2.1 Waiver for Certain Core Nursing Services, §40.5 Non-Core Services, §80 Hospice Pre-Election Evaluation and Counseling Services, §80.1 Documentation

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Medicare coverage of hospice care depends upon a physician's certification of an individual's prognosis of a life expectancy of 6 months or less, if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this Medicare Administrative Contractor (MAC) has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research and may be revised as more research is available. Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.

Patients will be considered to be in the terminal stage of their illness (life expectancy of 6 months or less) if they meet the following criteria:

Human Immunodeficiency Virus (HIV) Disease (1 and 2 must be present; factors from 3 will add supporting documentation)

1. Clusters of differentiation 4 (CD4)+ Count 100,000 copies/ml, plus 1 of the following:

a. Central Nervous System (CNS) lymphoma

b. Untreated, or not responsive to treatment, wasting (loss of 33% lean body mass)

c. Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused

d. Progressive multifocal leukoencephalopathy

e. Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy

f. Visceral Kaposi's sarcoma unresponsive to therapy

g. Renal failure in the absence of dialysis

h. Cryptosporidium infection

i. Toxoplasmosis, unresponsive to therapy

2. Decreased performance status as measured by the Karnofsky Performance Status (KPS) scale, of ≤ 50.

3. Documentation of the following factors will support eligibility for hospice care:

a. Chronic persistent diarrhea for 1 year

b. Persistent serum albumin <2.5

c. Concomitant, active substance abuse

d. Age > 50 years

e. Absence of antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease

f. Advanced acquired immunodeficiency syndrome (AIDS) dementia complex

g. Toxoplasmosis

h. Congestive heart failure (CHF), symptomatic at rest

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

1. Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record and must be made available to the A/B MAC upon request.

2. Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria outlined under the Coverage Indications, Limitations and/or Medical Necessity section of this policy would meet this requirement.

3. If the patient does not meet the criteria outlined under the Coverage Indications, Limitations and/or Medical Necessity section of this policy, yet is deemed appropriate for hospice care, sufficient documentation of the patient's condition that justifies terminal status, in the absence of meeting the above criteria, would be necessary.

4. Recertification for hospice care requires that the same standards be met as for initial certification.

Sources of Information

Medicare Contractors Medical Directors Hospice Workgroup

Bibliography

Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed. Evaluation of Chemotherapeutic Agents. 1st ed. New York, NY: Columbia University Press; 1949:191-205.

Nicholson JK, Hearn TL, Cross GD, White MD. 1997 Revised guidelines for performing CD4₊ T-cell determinations in persons infected with human immunodeficiency virus (HIV). Published January 10, 1997. Accessed September 28, 2021.

The National Hospice Organization (NHO). Medical guidelines for determining prognosis in selected non-cancer diseases. The Hospice Journal. 1996;11(2):47-63.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
11/04/2021	R12	Under *CMS National Coverage Policy* updated section headings for regulations and added §20.2.1.2 Hospice Election Statement and §20.2.1.3 Hospice Notice of Election to regulation CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting was corrected throughout the LCD.	Provider Education/Guidance
12/03/2020	R11	Under *CMS National Coverage Policy* updated description for Title XVIII of the Social Security Act, §1812(a)(4) and added section headings to the regulations. Formatting, punctuation and typographical errors were corrected and acronyms were inserted where appropriate throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/10/2019	R10	This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Hospice – HIV Disease A56677 article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/04/2019	R9	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Hospice – HIV Disease A56677 article and removed from the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
06/20/2019	R8	Under *Sources of Information* added Medicare Contractors Medical Directors Hospice Workgroup. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines and Medicare Contractors Medical Directors Hospice Workgroup was deleted. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
12/07/2017	R7	Under *Bibliography*, the fourth reference was corrected and changes were made to reflect AMA citation guidelines. Punctuation was corrected and acronyms were inserted or defined where appropriate throughout the policy. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Public Education/Guidance
12/07/2017	R6	Under *CMS National Coverage Policy* corrected grammatical errors. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance Typographical Error
01/05/2017	R5	Under *CMS National Coverage Policy* added the verbiage “Hospice Care” to 42 CFR Chapter IV, Part 418. Change Request 9369, Transmittal 3378, dated October 16, 2015 was deleted as the information has been manualized and the following reference was added: CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3. Under *Sources of Information and Basis for Decision* added supplement numbers and journal titles to various resources.	Provider Education/Guidance Other (Annual Validation)
01/01/2017	R4	Under *CPT/HCPCS Codes* the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
01/07/2016	R3	Under CMS National Coverage Policy added CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015; added reference to sections 20.1-20.4 to Publication 100-02, Chapter 9; added reference to sections 40.1-40.5 to Publication 100-02, chapter 9; and added reference to sections 80.1-80.2 to Publication 100-02, Chapter 9. Under Coverage Indications, Limitations and/or Medical Necessity changed intermediary to Medicare Administrative Contractor and made a few punctuation corrections throughout. Under CPT/HCPCS Codes added HCPCS codes G0299 and G0300.	Provider Education/Guidance Public Education/Guidance Revisions Due To CPT/HCPCS Code Changes Typographical Error Other (Annual validation)
10/01/2015	R2	Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.	Other (Bill type and revenue code removal)
10/01/2015	R1	Under CMS National Coverage Policy removed Title XVIII Section 1861 (dd) and Internet-Only Manual reference to 100-08, Chapter 13. Under Associated Information corrected the section title references to read “Coverage Indications, Limitations and /or Medical Necessity”. Under Sources of Information and Basis for Decision corrected all sources to meet AMA compliance and added source for CDC guidelines for performing CD4+ determinations	Provider Education/Guidance Other (Annual Validation)

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A56677 - Billing and Coding: Hospice – HIV Disease
A53056 - Hospice: Documenting Weight Loss for Beneficiaries with Non-Neoplastic Conditions

Updated On	Effective Dates	Status
10/29/2021	11/04/2021 - N/A	Currently in Effect	You are here
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Hospice - HIV Disease

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

General Information

Revision History Information

Associated Documents

Keywords

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