L31535-LCD

Automated World Health

Local Coverage Determination (LCD) for Hospice - HIV Disease (L31535)

Contractor Information

Contractor Name Palmetto GBA

Contractor Number 11004

Contractor Type HHH MAC

LCD Information

Document Information

LCD ID Number L31535

LCD Title Hospice - HIV Disease

Contractor's Determination Number J11AH-11-006-L

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

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South Carolina Tennessee Texas

Oversight Region Region IV

Original Determination Effective Date

For services performed on or after 01/24/2011 Original Determination Ending Date

Revision Effective Date

For services performed on or after 11/29/2012

Revision Ending Date

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861 (dd) the term "hospice care" means the services providered to a hospice patient

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), which consitute personal comfort items (except, in the case of hospice care, as it otherwise permitted under paragraph (1)(C)

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

Title XVIII of the Social Security Act, §1812 (a)(4) in lieu of certain benefits, hospice care with respect to the individual during up to two periods of 60 days each with respoce to which the individual makes an election under subsection (d)(1)

Title XVIII of the Social Security Act, §1813 (a)(4) drugs and biologicals provided in a hospice program Title XVIII of the Social Security Act, §1814 (a)(7) certifying the patient for hospice

42 CFR Chapter IV, Part 418

CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4,

§60

CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20, 40, and 80

CMS Manual System, Pub. 100-08 Medicare Program Integrity Manual, Chapter 13, §§13.1.1-13.13.14

Indications and Limitations of Coverage 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 six 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 intermediary 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 six months or less) if they meet the following criteria:

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

1. CD4+ Count <25 cells/mcL or persistent viral load >100,000 copies/ml, plus one of the following:

a. 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 one 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 AIDS dementia complex

g. Toxoplasmosis

h. Congestive heart failure, symptomatic at rest

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

081x Hospice (non-Hospital based) 082x Hospice (hospital based)

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

0651 Hospice Service - Routine Home Care 0652 Hospice Service - Continuous Home Care 0655 Hospice Service - Inpatient Respite Care

0656 Hospice Service - General Inpatient Care Non-Respite 0657 Hospice Service - Physician Services

CPT/HCPCS Codes

HCPCS codes for applicable physician services xx000 Not Applicable

ICD-9 Codes that Support Medical Necessity

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

Diagnoses that Support Medical Necessity

ICD-9 Codes that DO NOT Support Medical Necessity

795.71 NONSPECIFIC SEROLOGIC EVIDENCE OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) V01.79 CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES

V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

General Information

Documentations 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 “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy would meet this requirement.

3. If the patient does not meet the criteria outlined under “Indications and Limitations of Coverage 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.

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Karnofsky, DA & Burchenal, JH. (1949). “The Clinical Evaluation of Chemotherapeutic Agents in Cancer.” In McLeod CM (Ed), Evaluation of Chemotherapeutic Agents. Columbia Univ Press, 1949. Page 196.

Consultants, and other Medicare Medical Directors Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rest with the Intermediary, this policy was developed in cooperation with advisory groups, with includes representatives from the hospice provider community. Advisory Committee Meeting Date:

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/09/2010

Revision History Number Revision #1, Effective 11/29/2012

Revision History Explanation Revision #1, effective 11/29/2012

Under CMS National Policy the following citation is no longer valid: CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §80 and CMS Manual System, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §§60, 60.1 and 60.2. Under Documentation Requirements changed the word "Intermediary" to "A/B MAC." This revision becomes effective on 11/29/2012

01/24/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Palmetto GBA Title 18 RHHI (00380) was removed from this LCD and implemented to Palmetto GBA J11 HH and H MAC (11004). Effective date of this Implementation is January 24, 2011.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)