Hospice Care Admission Guidelines for Pulmonary Disease

LCD Guidelines

Pulmonary Disease

The criteria pertain to patients with advanced pulmonary disease who ultimately progress to end-stage pulmonary disease. Criteria 1 and 2 must be met, with Criteria 3, 4, and 5 serving as additional supporting evidence.

1. Severe Chronic Lung Disease characterized by:
   • Disabling Dyspnea at Rest: The patient suffers from severe breathlessness even while resting, which is minimally or not responsive to bronchodilators, resulting in significantly reduced functional capacity (e.g., limited to bed-to-chair mobility, persistent fatigue, and chronic coughing).
   • Progression of Pulmonary Disease: This is evidenced by a marked increase in hospital or emergency department visits for pulmonary infections or respiratory failure, or a rise in physician home visits prior to initial certification.
2. Resting Hypoxemia: The patient has abnormally low oxygen levels when breathing room air, indicated by a pO2 of ≤ 55 mmHg or an oxygen saturation of ≤ 88%, as measured by arterial blood gases or oxygen saturation monitors. These values may be verified using recent hospital records. Alternatively, Hypercapnia can be documented by a pCO2 of ≥ 50 mmHg, with values available from hospital records within the past 3 months.
3. Right Heart Failure (RHF): This condition, resulting from pulmonary disease (Cor pulmonale), is not due to left heart disease or valvular problems.
4. Progressive, Unintentional Weight Loss: The patient has experienced a loss exceeding 10% of their body weight over the previous 6 months.
5. Resting Tachycardia: The patient consistently has a resting heart rate of over 100 beats per minute.