Hospice eligibility guidelines: heart disease

What are the hospice eligibility indicators for heart disease?

Hospice eligibility for heart disease under the Medicare LCD guidance rests on two required indicators, optimal treatment and NYHA class IV symptoms. An ejection fraction of 20% or less and the other rows add support.

Read this table together with the general decline indicators and the non-disease-specific baseline (functional status and dependence in activities of daily living) on the eligibility guidelines overview.

What does optimally treated mean in practice?

In the heart disease LCD guidance, optimally treated means the patient is on the guideline-directed therapy they can tolerate, or there is a documented reason they are not, such as hypotension, renal dysfunction or patient choice. Reviewers read it this way because the guidance was written before several current heart failure drug classes existed. A patient does not have to fail every option. A patient who declines or is not a candidate for revascularization, valve intervention, device therapy, mechanical support or transplant fits the guidance.

Implantable defibrillators and inotrope infusions do not rule out hospice. Discuss defibrillator deactivation as part of goals of care. Tell us about infusions, ventricular assist devices and similar therapies at referral so the plan of care can address them. Patients on IV inotropes or with a ventricular assist device receive an individual clinical review before admission covering goals of care, prescriber involvement, equipment and infusion support, staff competency, emergency arrangements and payment responsibility.

What documentation supports hospice eligibility in heart disease?

Documentation that supports hospice eligibility in heart disease includes:

• NYHA class with the symptoms at rest that justify it: dyspnea, orthopnea, angina, fatigue, edema.
• Current cardiac medicines and doses, and the reason any standard therapy is absent or reduced.
• Most recent ejection fraction and date, if one exists.
• Hospitalizations and emergency visits for heart failure in the past six to twelve months.
• Weight trend, noting that fluid shifts can mask loss of lean mass. Signs of cardiac cachexia.
• Renal function, serum sodium and blood pressure trends, which add prognostic information.
• Cardiology notes stating the patient is not a candidate for, or has declined, procedures or advanced therapies.
• PPS or KPS score and dependence in activities of daily living.

How do comorbidities affect hospice eligibility in heart disease?

In heart disease, chronic kidney disease, chronic lung disease, diabetes and dementia are the comorbidities that most often tip the prognosis. A patient with class III symptoms, worsening renal function and three admissions in six months may still be appropriate. Document the pattern.

The Medicare hospice LCD guidance weighs comorbidities as well as the primary diagnosis. The presence and severity of conditions such as chronic obstructive pulmonary disease, congestive heart failure, ischemic heart disease, diabetes, neurologic disease (stroke, ALS, multiple sclerosis, Parkinson's disease), renal failure, liver disease, malignancy, AIDS and dementia can support a prognosis of six months or less even when the primary diagnosis alone does not. Document each one with its current severity and how it limits the patient.

What if you are not sure a patient is eligible for hospice?

If you are not sure a patient is eligible for hospice, call Beta Hospice and talk the case through with a hospice nurse, or ask for a physician-to-physician conversation with our medical director. A call is not a referral and does not commit the patient to anything. Heart failure tends to decline in steps, with partial recovery after each exacerbation, so the right time is easy to miss. Prognosis is rarely clear cut.

If the patient is not hospice eligible now, we will say so and tell you what we would watch for. Some patients are better served by palliative care first. When you are ready, use Refer a patient. The hospice medical director, with the attending physician if there is one, makes the certification decision under 42 CFR 418.22.

A page you can share with the family

Beta Hospice's family guide, hospice care for heart failure, explains in plain language what hospice does for this illness, what signs are worth raising with a doctor or nurse, and how care is paid for. It does not give an eligibility verdict. Families often ask the same questions you are weighing, in different words. You are welcome to share it before or after a goals-of-care conversation.