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
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