L31541-LCD

Automated World Health

Local Coverage Determination (LCD) for Hospice The Adult Failure To Thrive Syndrome (L31541)

Contractor Information

Contractor Name Palmetto GBA

Contractor Number 11004

Contractor Type HHH MAC

LCD Information

Document Information

LCD ID Number L31541

LCD Title Hospice The Adult Failure To Thrive Syndrome

Contractor's Determination Number J11AH-11-012-L

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. 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.

Primary Geographic Jurisdiction Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi North Carolina New Mexico Ohio Oklahoma 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. 100-1, Medicare General Information, Eligibility, and Entitlement, Chapter 4, §60 CMS Manual System, Pub 100-2, Medicare Benefit Policy, 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

The adult failure to thrive syndrome is characterized by unexplained weight loss, malnutrition and disability.1 The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes two defining clinical elements, namely nutritional impairment and disability. The nutritional impairment and disability associated with the adult failure to thrive syndrome may be severe enough to impact on the patient’s short-term survival.

The adult failure to thrive syndrome may manifest as an irreversible progression in the patient’s nutritional impairment/disability despite a trial of therapy (i.e., treatment intended to effect the primary condition responsible for the patient’s clinical presentation). The presence of comorbid conditions may hasten the patient’s clinical progression and as such should be identified and addressed. 2 This hospice policy addresses those cases where reversible causes of severe nutritional impairment and disability (i.e., the adult failure to thrive syndrome) have been excluded.

The Medicare Hospice Benefit is predicated upon physician-certification that an individual entitled to Part A of Medicare is terminally ill. An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is six months or less if the terminal illness runs its normal course. 3 The medical criteria listed below would support a terminal prognosis for individuals with the adult failure to thrive syndrome. Medical criteria 1 and 2 are important indicators of nutritional and functional status respectively, and would thus support a terminal prognosis if met.

1. The nutritional impairment associated with the adult failure to thrive syndrome should be severe enough to impact on a beneficiary's weight. It is expected that the Body Mass Index (BMI) of beneficiaries electing the Medicare Hospice Benefit for the adult failure to thrive syndrome will be below 22 kg/m 2 and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

BMI (kg/m 2)=703 x (weight in pounds) divided by (height in inches) 2

2. The disability associated with the adult failure to thrive syndrome should be such that the individual is significantly disabled. Significant disability would be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%. 4

Both the beneficiary's BMI and level of disability should be determined using measurements/observations made within six months (180 days) of the most recent certification/recertification date. If enteral nutritional support has been instituted prior to the election of the Hospice Medicare Benefit and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification.

At the time of recertification recumbent measurement(s) (anthropometry) such as mid-arm muscle area in cm 2 may be substituted for BMI with documentation as to why a BMI could not be measured. This information will be subject to review on a case by case basis.

In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.21 "abnormal loss of weight" and 799.4 "Cachexia")

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

783.41 FAILURE TO THRIVE

783.7 ADULT FAILURE TO THRIVE

799.3 DEBILITY UNSPECIFIED

799.89 OTHER ILL-DEFINED CONDITIONS

799.9 OTHER UNKNOWN AND UNSPECIFIED CAUSE OF MORBIDITY OR MORTALITY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

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

Diagnoses that DO NOT Support Medical Necessity N/A

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 Intermediary upon request.

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

3. While data collection instruments such as checklists may facilitate the evaluation of nutritional impairments and disability at the time of certification/recertification, the medical record should substantiate the degree of nutritional impairment/disability noted on such instruments.

4. A current BMI determined using the beneficiary's height and weight measured:

A. within six months (180 days) of the most recent certification/recertification date for beneficiaries without enteral nutritional support; or

B. at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

5. If recumbent anthropometry is substitiued for BMI at recertification the rationale should be documented.

6. A current evaluation of the beneficiary's functional status demonstrating a level of disability equivalent to that described by a Karnofsky or Palliative Performance Scale value of less than or equal to 40%, determined:

A. within a six month period (180 days) from the most recent certification/recertification date for beneficiaries with enteral nutritional support, or

B. at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

Appendices N/A

Utilization Guidelines N/A

Sources of Information and Basis for Decision

1. Fried L and Walston J: Frailty and Failure to Thrive in PrinciplesofGeriatricMedicineandGerontology, Hazzard WR, Blass JP, Ettinger WH et al (eds); the McGraw Hill Companies, Inc., 1999.

2. Verdery RB: Clinical evaluation of failure to thrive in older people. ClinGeriatrMed. 1997 Nov;13(4):769-78.

3. Title XVIII-Health Insurance for the Aged and Disabled: Part C Miscellaneous Provisions; Section 1861(3)(A).

4. Anderson F, Downing GM, Hill J. et al: Palliative performance scale (PPS): A new tool. JournalofPalliativeCare 12:1996;5-11..

5. 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. 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, 11/29/2012

Under CMS National Coverage Policy the following citations have been deleted: CMS Manual System, Pub 100- 01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 5, §§60, 60.1 and 60.2, CMS Manual System, Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual.Ch 4, §80 and CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§30, 40, 50, 60 and 70. Added

§80 to Pub 100-02, Ch 9. 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.)