Ind. IHCP Hospice Services Provider Reference Module, Section 5, Hospice Authorization Guidelines for Medical Necessity Review

Hospice care is dependent upon a physician certification stating a member’s prognosis of life expectancy

is six months or less, if the terminal illness runs its normal course. In addition, the services provided in

hospice care must be reasonable and meet medical necessity for the palliation or management of the

terminal illness. Coverage for hospice care is strongly dependent on documentation of the member’s

condition as recorded in the provider’s records. Documentation is used in the prior authorization an d

review process to determine the presence of medical necessity. Each case will be evaluated on its own

merit. The existence of documented comorbidities, as well as the documentation of decline in the member’s

health status, is used in the evaluation. Existence of a patient advance directive should al so be taken into

consideration.

The IHCP uses existing medical documentation submitted by the hospice provider to determine medical

necessity for hospice. Existing labs and other forms of medical tests may be helpful in determining

appropriateness of hospice care and may be requested of the provider if such documentation exists;

however, the IHCP would not expect the patient to undergo invasive tests at the end of life unless

absolutely necessary to validate a prognosis. The IHCP and its contractors a re not prevented from

requesting medical documentation about any hospice member at any point during that member’s

enrollment in the IHCP. This practice is consistent with the IHCP Provider Agreement.

Providers should use the criteria in national clinical guidelines to assist in determining medical necessity of

hospice services for persons with various medical conditions.