LCD L34567

Coverage Guidance

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) states payment under this part may be made for hospice care provided with respect to an individual only during 2 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) states the term "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, §10.1 General 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

Indications and Limitations of Coverage

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 AD. 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 6 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

N/A

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 HHH MAC upon request.

Bibliography

Geldmacher DS. Differential diagnosis of dementia syndromes. Clin Geriatr Med. 2004;20(1):27-43.

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

Kertesz A, Munoz DG. Frontotemporal dementia. Med Clin N Am. 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. Clin Geriatr Med. 2000;16(2):373-386.