HOSPICE HIV

 

INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY:
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 less than or equal to 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

If you have any questions please call us:

Grace Hospice of Texas

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