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Local Coverage Determination for HIV


The Medicare Administrative Contractors (MACs) Cigna Government Services (CGS), National Government Services (NGS), and Palmetto set disease-specific criteria for eligibility for Human Immunodeficiency Virus (HIV) disease that include assessing the non-disease specific criteria alongside the disease-specific criteria.

As with all diagnoses for hospice patients, ultimately the eligibility is determined by the physician’s narrative statement in the Certification of Terminal Illness (CTI) of the specific reasons (including these LCD criteria) the patient has a prognosis of six months or less if the disease runs its expected course. As more people living with HIV do not progress to advanced disease with the improved efficacy of HIV treatments, the criteria set by the MACs is especially useful for agencies to determine if a patient is at the terminal phase of the disease.

Hospice Eligibility for HIV Patients

All three MACs agree on the specific criteria needed to show eligibility for hospice services for HIV disease. The laboratory values that indicate advanced HIV are a CD4 count of fewer than 25 cells/mcl or a persistent (defined as two or more viral load assays at least one month apart) viral load of greater than 100,000 copies/ml.

The laboratory values must be paired with at least one of the following opportunistic infections or disease processes:

  • CNS lymphoma
  • Untreated, or persistent despite treatment, wasting (loss of at least 10% lean body mass)
  • Mycobacterium avium complex (MAC) bacteremia, untreated, unresponsive to treatment, or treatment refused
  • Progressive multifocal leukoencephalopathy
  • Systemic lymphoma, with advanced HIV disease and partial response to chemotherapy
  • Visceral Kaposi’s sarcoma unresponsive to therapy
  • Renal failure in the absence of dialysis
  • Cryptosporidium infection
  • Toxoplasmosis, unresponsive to therapy

In addition to the laboratory values with the opportunistic infection or disease process, the MACs also state that the patient should have a Karnofsky Performance Scale (KPS) equal to or below 50%.

Identifying the Terminal vs. Chronic Phase of HIV

To further demonstrate that the patient is in the terminal phase of HIV disease, documenting the following additional conditions in the hospice software is suggested:

  • Chronic persistent diarrhea for one year
  • Persistent serum albumin less than 2.5
  • Concomitant, active substance abuse
  • Age greater than 50 years
  • Absence of or resistance to effective antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease
  • Advanced AIDS dementia complex
  • Toxoplasmosis
  • Congestive heart failure, symptomatic at rest
  • Advanced liver disease (not listed for Palmetto)

All MACs expect the hospice to determine the diagnoses that are related to the patient’s terminal prognosis and address all in the CTI narrative. Furthermore, accurately identifying and assessing the patient’s full diagnoses will assist agencies with developing the most accurate and proactive plan of care for addressing the patient’s needs at the present time and during the hospice admission.

For patients with HIV disease, it is safest to obtain recent laboratory history prior to admission, as well as a thorough medical history to determine the presence of opportunistic infections or disease processes. If the patient does not meet all areas of the LCD, but the hospice physician believes the patient is eligible for hospice, ensure the physician documents a clear CTI narrative in the hospice software hospice software showing the patient’s eligibility for hospice services.

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