Hospice eligibility guidelines.
Hospice is an option when a doctor believes time may be six months or less.
For you or your loved one
You do not need to read the clinical criteria. Five questions will tell you whether this is worth a conversation, and a nurse will confirm either way.
For referring clinicians
The full Medicare criteria are below, general first and then by diagnosis, with the thresholds intact. Printable, and every condition has its own link.
There are two ways to qualify.
Only one of these routes has to be met. They are not steps, and they are not cumulative.
Route A
Decline in clinical status, on its own
- Documented, non-reversible decline measured against an earlier baseline
- No disease-specific criteria needed
- Baseline and follow-up documentation are both required
Route B
Baseline status, plus the disease guideline
- PPS or KPS under 70 percent, and dependence in two or more activities of daily living
- Plus the guideline for the patient's primary diagnosis
- Comorbidities support the picture but do not qualify a patient alone
Judgment governs, not the checklist.
A patient who does not meet either route may still be eligible when the documentation supports a prognosis of six months or less. These are guidelines rather than a scoring tool, and clinical judgment about the trajectory of the illness governs.
Two things that do not change.
Care continues past six months for as long as the criteria are still met. And you or your loved one can stop hospice at any time if goals change.
General indicators.
Any one of these is reason enough to start a conversation. A referral is never wasted, and we will say so if it is too early.
Route A
Decline in clinical status
Decline must be documented against a prior baseline, and must not be reversible.
Infection and nutrition
- Recurrent or intractable serious infections such as pneumonia, sepsis, or pyelonephritis
- Weight loss of 10 percent or more in the last six months, not explained by a reversible cause such as depression or diuretics
- Decreasing anthropomorphic measurements, ill-fitting clothing, falling serum albumin or cholesterol
- Dysphagia with recurrent aspiration or inadequate intake
Symptoms
- Dyspnea with an increasing respiratory rate
- Intractable cough
- Nausea and vomiting poorly responsive to treatment
- Intractable diarrhea
- Pain requiring escalating major analgesics
Signs
- Systolic blood pressure under 90, or progressive postural hypotension
- Ascites, edema, pleural or pericardial effusion
- Venous, arterial, or lymphatic obstruction
- Weakness, or altered level of consciousness
Function
- Decline in KPS or PPS from disease progression
- FAST progression beyond stage 7A
- Progressive new dependence in activities of daily living
- Progressive stage 3 or 4 pressure ulcers despite optimal care
- Increasing emergency visits, hospitalizations, or physician visits related to the hospice diagnosis before election
Laboratory findings are not required. Rising pCO2, falling pO2, rising calcium, creatinine, liver function tests, or tumour markers all support the picture. None of them is a condition of eligibility.
Route B
Baseline status
Both items below should be met, then apply the disease guideline in the next section.
1. Performance status
- Karnofsky or Palliative Performance Scale under 70 percent
2. Dependence in daily activities
- Dependence on assistance for two or more of: ambulation, continence, transfer, dressing, feeding, bathing
3. Comorbidities
Supportive only. These strengthen a prognosis but do not qualify a patient on their own.
- COPD, congestive heart failure, ischemic heart disease
- Diabetes mellitus
- Neurologic disease including stroke, ALS, multiple sclerosis, Parkinson disease
- Renal failure, liver disease, neoplasia, AIDS, dementia
- Refractory severe autoimmune disease such as lupus or rheumatoid arthritis
The strongest single predictor. The policy notes that ongoing weight loss predicts a poor prognosis better than most indicators, and that declining functional status on its own predicts it less well.
Criteria by diagnosis.
Written for referring physicians and case managers. Apply these with the Route B baseline above. Bold marks the threshold that decides the criterion.
ALS
No tracheostomy or invasive ventilation, plus critically impaired breathing, severe nutritional insufficiency, or both.
Both of the following
- The patient has not elected tracheostomy and invasive ventilation
- Critically impaired respiratory function, or severe nutritional insufficiency, or both
Critically impaired respiratory function
- Forced vital capacity under 40 percent predicted, seated or supine, with or without non-invasive ventilation
- Plus at least two of: dyspnea at rest, orthopnea, accessory muscle use, paradoxical abdominal motion, respiratory rate over 20, reduced speech or vocal volume, weakened cough, sleep-disordered breathing, frequent awakening, daytime somnolence, unexplained headache, confusion, anxiety, nausea
- If forced vital capacity cannot be performed, at least three of those signs and symptoms
Severe nutritional insufficiency
- Dysphagia with progressive weight loss of at least 5 percent of body weight, with or without election of a gastrostomy tube
Arizona note. Many hospice sites publish a vital capacity under 30 percent criterion for ALS. That figure comes from a different regional Medicare policy and does not apply to Arizona patients. The threshold here is forced vital capacity under 40 percent predicted.
Cancer
Metastatic disease, with continued decline despite treatment or a decision to stop disease-directed treatment.
Either of the following
- Disease with metastases at presentation
- Progression from an earlier stage to metastatic disease, with either continued decline despite therapy or the patient declining further disease-directed therapy
Poor-prognosis cancers
- Small cell lung cancer, brain cancer, and pancreatic cancer may be eligible without meeting the other criteria in this section
Stroke and coma
Stroke: PPS under 40 percent with an inability to maintain hydration and calories. Coma: three of four findings on day three.
Stroke, both required
- Karnofsky or Palliative Performance Scale under 40 percent
- Inability to maintain hydration and caloric intake, with one of: weight loss over 10 percent in six months or over 7.5 percent in three months; serum albumin under 2.5 g/dl; current history of pulmonary aspiration not responsive to speech pathology intervention; dysphagia severe enough that life-sustaining food and fluids cannot continue without artificial nutrition
Coma of any cause, three of these four on day three
- Abnormal brain stem response
- Absent verbal response
- Absent withdrawal response to pain
- Serum creatinine over 1.5 mg/dl
Supportive, not required
- Aspiration pneumonia, pyelonephritis, refractory stage 3 or 4 pressure ulcers, or fever recurring after antibiotics, within the last 12 months
Dementia
FAST stage 7 or beyond, plus one qualifying medical complication in the past 12 months.
All of the following
- FAST stage 7 or beyond
- Unable to ambulate without assistance
- Unable to dress without assistance
- Unable to bathe without assistance
- Urinary and fecal incontinence, intermittent or constant
- No consistently meaningful verbal communication: stereotypical phrases only, or an intelligible vocabulary of six or fewer words
Plus one of these in the past 12 months
- Aspiration pneumonia
- Pyelonephritis
- Septicemia
- Multiple stage 3 or 4 pressure ulcers
- Fever recurring after antibiotics
- Inability to maintain sufficient fluid and calorie intake, with 10 percent weight loss in the previous six months or serum albumin under 2.5 g/dl
Heart disease
NYHA Class IV symptoms at rest, despite optimal medical management.
Both of the following
- Optimally treated: on diuretics and vasodilators, meaning an ACE inhibitor, or hydralazine and nitrates if the patient cannot tolerate an ACE inhibitor. A patient not on vasodilators still counts as optimally treated when there is a medical reason, such as hypotension or renal disease
- Congestive heart failure or angina at rest meeting NYHA Class IV: unable to carry on any physical activity without discomfort, symptoms present at rest, and any activity increases discomfort
Supportive, not required
- Treatment-resistant symptomatic supraventricular or ventricular arrhythmias
- History of cardiac arrest or resuscitation, or unexplained syncope
- Brain embolism of cardiac origin
- Concomitant HIV disease
Ejection fraction is not a gate. An ejection fraction of 20 percent or less supports the diagnosis, but it is not required and does not need to be obtained if it is not already on file.
HIV and AIDS
CD4 under 25 cells/mcL or viral load over 100,000 copies/mL, plus a qualifying condition, plus KPS of 50 percent or less.
Laboratory result plus a qualifying condition
- CD4 count under 25 cells/mcL, or a persistent viral load over 100,000 copies/mL on two or more assays at least one month apart
- Plus one of: central nervous system lymphoma; untreated or persistent wasting with loss of 10 percent or more of lean body mass; Mycobacterium avium complex bacteremia that is untreated, unresponsive, or where treatment was refused; progressive multifocal leukoencephalopathy; systemic lymphoma with advanced HIV and a partial response to chemotherapy; visceral Kaposi sarcoma unresponsive to therapy; renal failure in the absence of dialysis; cryptosporidium infection; toxoplasmosis unresponsive to therapy
Performance status
- Karnofsky Performance Status of 50 percent or less
Supportive, not required
- Chronic persistent diarrhea for one year
- Serum albumin persistently under 2.5 g/dl
- Concomitant active substance use
- Age over 50
- Absence of, or resistance to, effective antiretroviral, chemotherapeutic, and prophylactic therapy
- Advanced AIDS dementia complex, toxoplasmosis, congestive heart failure symptomatic at rest, or advanced liver disease
Do not use the AIDS-defining number. A CD4 count under 200 defines AIDS. The hospice threshold is under 25 cells/mcL.
Liver disease
INR over 1.5 and albumin under 2.5 g/dl, plus one end-stage complication.
Both laboratory findings
- Prothrombin time prolonged more than 5 seconds over control, or INR over 1.5
- Serum albumin under 2.5 g/dl
Plus at least one end-stage complication
- Ascites refractory to treatment, or the patient is not able to follow the treatment
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome: elevated creatinine and BUN with oliguria under 400 ml per day and urine sodium under 10 mEq/l
- Hepatic encephalopathy refractory to treatment, or the patient is not able to follow the treatment
- Recurrent variceal bleeding despite intensive therapy
Supportive, not required
- Progressive malnutrition, muscle wasting with reduced strength and endurance
- Continued active alcohol use above 80 g of ethanol per day
- Hepatocellular carcinoma
- Hepatitis B surface antigen positive
- Hepatitis C refractory to interferon treatment
Pulmonary disease and COPD
Disabling dyspnea at rest that does not respond to bronchodilators, with hypoxemia or hypercapnia.
Severe chronic lung disease, both required
- Disabling dyspnea at rest, poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity
- Progression of disease shown by increasing emergency visits, hospitalizations for pulmonary infection or respiratory failure, or increasing physician home visits
Plus hypoxemia or hypercapnia
- Hypoxemia at rest on room air: pO2 of 55 mmHg or less, or oxygen saturation of 88 percent or less
- Or hypercapnia: pCO2 of 50 mmHg or more
Supportive, not required
- Cor pulmonale or right heart failure secondary to pulmonary disease, not secondary to left heart disease or valvulopathy
- Unintentional progressive weight loss over 10 percent of body weight in the preceding six months
- Resting tachycardia over 100 per minute
FEV1 is not a gate. A post-bronchodilator FEV1 under 30 percent predicted is objective evidence of disabling dyspnea, but the policy states it is not necessary to obtain. Do not delay a referral to get one.
Renal disease
The patient is not seeking dialysis or transplant, or is discontinuing dialysis, with end-stage renal values.
Acute renal failure, item 1 plus any one of 2, 3, or 4
- 1. Not seeking dialysis or renal transplant, or discontinuing dialysis
- 2. Creatinine clearance under 10 cc/min, or under 15 cc/min for diabetics. With comorbid congestive heart failure, under 15 cc/min, or under 20 cc/min for diabetics
- 3. Serum creatinine over 8.0 mg/dl, or over 6.0 mg/dl for diabetics
- 4. Estimated glomerular filtration rate under 10 ml/min
Chronic renal failure, item 1 plus any one of 2, 3, 4, or 5
- Items 1 through 3 as above
- 4. Signs and symptoms of renal failure: uremia, oliguria under 400 cc in 24 hours, intractable hyperkalemia over 7.0 mEq/l not responsive to treatment, uremic pericarditis, hepatorenal syndrome, or intractable fluid overload unresponsive to treatment
- 5. Estimated glomerular filtration rate under 10 ml/min
Supportive comorbidities in acute renal failure
- Mechanical ventilation, malignancy of another organ system, chronic lung disease, advanced cardiac disease, advanced liver disease, immunosuppression or AIDS
- Serum albumin under 3.5 g/dl, platelet count under 25,000, disseminated intravascular coagulation, gastrointestinal bleeding
No condition matches that. Call 480.321.8455 and a nurse will answer.
Where these criteria come from
Criteria on this page are taken from the Medicare Local Coverage Determination that governs hospice eligibility in Arizona, L33393, Hospice: Determining Terminal Status. Criteria differ by region, so criteria published by hospices in other states may not apply here.
How it is paid for.
We verify coverage before care begins, and we tell you what we find.
Medicare Part A
Covers hospice care for most patients, including the care team, medications related to the illness, equipment, and supplies.
Medicaid and AHCCCS
Covers hospice with benefits that closely follow the Medicare hospice benefit.
HMO and private insurance
Most plans include a hospice benefit. We check yours and confirm what it covers before care starts.
Where to go next.
What hospice includes
The team, the visits, the equipment, and the medications covered.
What happens after you call
The steps from first call to first visit, in order and with timing.
Not sure if you or your loved one qualifies?
Call and we will tell you honestly, either way.
480.321.8455Get care started
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A nurse answers 24 hours a day. Online requests are coming soon. For anything about care, calling is fastest.