Local Coverage Determination (LCD)

Hospice Alzheimer's Disease & Related Disorders

L34567

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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
L34567

LCD Title
Hospice Alzheimer's Disease & Related Disorders

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 11/11/2021

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, §1812(a)(4) States in lieu of certain other benefits, hospice care with respect to the which the individual makes an election.

Title XVIII of the Social Security Act, §1812(d)(1) Payment under this part may be made for hospice care provided with respect to an individual only during two periods of 90 days each and an unlimited number of subsequent periods of 60 days each during the individual’s lifetime and only, with respect to each such period, if the individual makes an election under this paragraph to receive hospice care under this part provided by, or under arrangements made by, a particular hospice program instead of certain other benefits under this title.

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

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

Title XVIII of the Social Security Act, §1861(dd) the term states "hospice care" means the services provided to a terminally ill individual.

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

42 CFR Chapter IV, Part 418; Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1.§10.1General Program Benefits Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health, and Skilled Hospice, Home Health, and Skilled Nursing Facility (SNF) Services - A Brief Description.

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 and §80 Summary Table for Certifications/Recertifications

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §60 Hospice Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20.1 Timing and Content of Certification, §30 Coinsurance, §40 Benefit Coverage, §50 Limitation on Liability for Certain Hospice Coverage Denials, §60 Provision of Hospice Services to Medicare/Veteran's Eligible Beneficiaries, §70 Hospice Contracts with an Entity for Services not Considered Hospice Services, and §80 Hospice Pre-Election Evaluation and Counseling Services

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Alzheimer’s Disease (AD) and related disorders may support a prognosis of 6 months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of AD are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with AD are by definition distinct from the AD itself. Examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions, on the other hand, are directly related to a primary condition. In the case of AD examples include delirium and pressure ulcers. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.

The Reisberg Functional Assessment Staging (FAST) scale has been used for many years to describe Medicare beneficiaries with AD and a prognosis of 6 months or less. The FAST scale is a 16-item scale designed to parallel the progressive activity limitations associated with AD. Stage 7 identifies the threshold of activity limitation that would support a 6 month prognosis. The FAST scale does not address the impact of comorbid and secondary conditions. These 2 variables are thus considered separately by this policy.

FAST Scale Items:

Stage #1: No difficulty, either subjectively or objectively

Stage #2: Complains of forgetting location of objects; subjective work difficulties

Stage #3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations

Stage #4: Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances)

Stage #5: Requires assistance in choosing proper clothing

Stage #6: Decreased ability to dress, bathe, and toilet independently:
· Sub-stage 6a: Difficulty putting clothing on properly
· Sub-stage 6b: Unable to bathe properly; may develop fear of bathing
· Sub-stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)
· Sub-stage 6d: Urinary incontinence
· Sub-stage 6e: Fecal incontinence

Stage #7: Loss of speech, locomotion, and consciousness:
· Sub-stage 7a: Ability to speak limited (1 to 5 words a day)
· Sub-stage 7b: All intelligible vocabulary lost
· Sub-stage 7c: Non-ambulatory
· Sub-stage 7d: Unable to sit up independently
· Sub-stage 7e: Unable to smile
· Sub-stage 7f: Unable to hold head up.

Comorbid Conditions:

The significance of a given comorbid condition is best described by defining the structural/functional impairments, together with any limitation in activity, related to the comorbid condition. For example a beneficiary with AD and clinically significant CHD or COPD would have specific impairments of cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, chest pain), which may or may not respond or be amenable to treatment. The identified impairments in cardiorespiratory function would be associated with both specific structural impairments of the coronary arteries or bronchial tree, and may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the AD (FAST stage 7 or beyond) and any comorbid condition should be such that most beneficiaries with AD (FAST stage 7 or beyond) and similar impairments would have a prognosis of 6 months or less.

Secondary Conditions:

AD may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments, together with any limitation in activity, related to the secondary condition. The occurrence of secondary conditions in beneficiaries with AD is facilitated by the presence of impairments in such body functions as mental functioning and movement functions. Such functional impairments contribute to the increased incidence of secondary conditions, such as delirium and pressure ulcers, observed in Medicare beneficiaries with Alzheimer’s Disease. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond or be amenable to treatment. Ultimately, the combined effects of the AD (FAST stage 7 and beyond) and any secondary condition should be such that most beneficiaries with AD and similar impairments would have a prognosis of months or less.

The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. curative) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare Hospice Services.

Summary:

For beneficiaries with AD to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions meeting the above criteria.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information

Documentation Requirements

Documentation certifying terminal status must contain enough information to confirm terminal status upon review. Documentation meeting the criteria listed under the Coverage Indications, Limitations and/or Medical Necessity section of this Local Coverage Determination (LCD) would contribute to this requirement. Re-certification for hospice care requires that the same standards be met as for the initial certification.

Documentation should be legible and made available to the A/B MAC (HHH) upon request.

Sources of Information
N/A

Bibliography

Geldmacher DS. Differential diagnosis of dementia syndromes. Clinics in Geriatric Medicine. 2004;20(1):27-43.

Hodges JR. Frontotemporal dementia (pick’s disease):clinical features and assessment. Neurology. 2001;56(11 Suppl 4):S6-10.

International classification of functioning, disability and health: ICF. Geneva: World Health Organization, 2001.

Kertesz A, Munoz DG. Frontotemporal dementia. Medical Clinics of North America. 2002;86(3):501-18.

Pope AM, Tarlov AR. Disability in America: toward a national agenda for prevention. Washington, DC: National Academy Press; 1991.

Reisberg B. Functional assessment staging (FAST). Psychopharmacology Bulletin. 1988;24(4):653-659.

Shuster JL. Palliative care for advanced dementia. Clinics in Geriatric Medicine. 2000;16(2):373-386.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
11/11/2021	R11	Under *CMS National Coverage Policy* updated regulation descriptions and section headings. This revision will become effective 11/11/21.	Provider Education/Guidance
10/31/2019	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. CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3. was removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Hospice Alzheimer’s Disease & Related Disorders A56639 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 Alzheimer’s Disease & Related Disorders A56639 article and removed from the LCD. Formatting, punctuation and typographical errors were corrected 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
05/02/2019	R8	Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD. 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
04/26/2018	R7	Under *CMS National Coverage Policy* added section 80 to the CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 9, and added (D) to Title XVIII of the Social Security Act, Section 1814(D)(i). Under *Coverage Indications, Limitations and/or Medical Necessity* changed each of the words “scale” to lower case in the second paragraph, removed bold lettering from the Stage #7 subheading, and changed the slash to “or” in the paragraph titled *Comorbid Conditions. All Citations were moved from the Sources of Information and Basis for Decision* section to the Bibliography section. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Punctuation was corrected 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
01/01/2017	R6	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
04/28/2016	R5	Under *CMS National Coverage Policy* deleted the following sections cited for Title XVIII of the Social Security Act:§§1102 and 1871. The verbiage “Manual” was added to 4 cited references. Section 20.2 was deleted and sections 20.2.1, 20.2.1.1, 20.2.2, 20.2.3, and 20.2.4 were added to the following: CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20.1, 20.2, 20.3,40, 50, 60, and 70. Change Request 9369 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* author initials and page numbers were added to Kertesz A, Munoz DG. Frontotemporal Dementia. Medical Clinics of North America. 2002;86(3):501-18. The author name “Link” was deleted and corrected to now read “Tarlov” in the following: Pope AM, Tarlov AR. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991. The supplement number was added for Reisberg B. Functional Assessment Staging (FAST). Psychopharmacology Bulletin. 1988;24(4):653-659.	Provider Education/Guidance Other
01/01/2016	R4	Under CMS National Coverage Policy section added CMS Internet-Only Manual, Pub 100-04 Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015. Under CPT/HCPCS Codes section added HCPCS codes G0299 and G0300.	Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R3	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/or revenue code removal)
10/01/2015	R2	Under Coverage Indications, Limitations and/or Medical Necessity under the section Comorbid Conditions in the last sentence added “FAST Stage 7 and beyond” after Alzheimer’s disease. In section Secondary Conditions in the last sentence added “and beyond”. Under Associated Information documentation requirements added “Coverage” to second sentence and corrected the title to read Coverage Indications, Limitations and /or Medical Necessity.	Provider Education/Guidance Other (Annual Validation)
10/01/2015	R1	In CMS National Coverage Policy under the 42 CFR added Hospice Care. In Coverage Indications, Limitations and/or Medical Necessity made a few grammatical and punctuation corrections. Under Comorbid Conditions subheading changed (stage 7) to read (FAST Stage 7 and beyond). In Sources of Information and Basis for Decision corrected citations to conform to AMA formatting.	Other (Maintenance - Annual validation)

Associated Documents

Attachments
N/A

Updated On	Effective Dates	Status
11/01/2021	11/11/2021 - N/A	Currently in Effect	You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

Hospice
Alzheimer's Disease
Hospice Alzheimer's Disease & Related Disorders

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Hospice Alzheimer's Disease & Related Disorders

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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