Local Coverage Determination (LCD)

Hospice The Adult Failure To Thrive Syndrome

L34558

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
Palmetto GBA	A and B and HHH MAC	11004 - HHH MAC	J - M	Alabama Arkansas Florida Georgia Illinois Indiana Kentucky Louisiana Mississippi New Mexico North Carolina Ohio Oklahoma South Carolina Tennessee Texas

LCD Information

Document Information

LCD ID
L34558

LCD Title
Hospice The Adult Failure To Thrive Syndrome

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 01/04/2024

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1861(dd) states the term "hospice care" means the services provided to a terminally ill individual.

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Title XVIII of the Social Security Act, §1862(a)(6) addresses items and services which constitute personal comfort items (except, in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1862(a)(9) addresses items and services where such expenses are for custodial care (except in the case of hospice care, as is otherwise permitted).

Title XVIII of the Social Security Act, §1812(a)(4) states in lieu of certain benefits, hospice care with respect to the individual during up to 2 periods of 90 days each with an unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election.

Title XVIII of the Social Security Act, §1813(a)(4) addresses drugs and biologicals provided in a hospice program.

Title XVIII of the Social Security Act, §1814(a)(7) addresses certifying the patient for hospice.

42 CFR Part 418 Hospice Care

CMS Internet-Only Manual, Pub. 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60 Certification and Recertification by Physicians for Hospice Care

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 9, §10 Requirements - General, §20.1 Timing and Content of Certification, §20.2.1 Hospice Election, §30 Coinsurance, §40 Benefit Coverage, §50 Limitation on Liability for Certain Hospice Coverage Denials, §60 Provision of Hospice Services to Medicare/Veteran's Eligible Beneficiaries, §70 Hospice Contracts with an Entity for Services not Considered Hospice Services, and §80 Hospice Pre-Election Evaluation and Counseling Services.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

The adult failure to thrive (FTT) syndrome is characterized by unexplained weight loss, malnutrition and disability. The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes 2 defining clinical elements, namely nutritional impairment and disability. The nutritional impairment and disability associated with the adult FTT syndrome may be severe enough to have an impact on the patient’s short-term survival.

The adult FTT syndrome may manifest as an irreversible progression in the patient’s nutritional impairment/disability despite a trial of therapy (i.e., treatment intended to affect the primary condition responsible for the patient’s clinical presentation). The presence of comorbid conditions may hasten the patient’s clinical progression and as such should be identified and addressed. This hospice policy addresses those cases where reversible causes of severe nutritional impairment and disability (i.e., the adult FTT syndrome) have been excluded.

The Medicare hospice benefit is predicated upon physician-certification that an individual entitled to Part A of Medicare is terminally ill. An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is 6 months or less if the terminal illness runs its normal course. The medical criteria listed below would support a terminal prognosis for individuals with the adult FTT syndrome. Medical criteria 1 and 2 are important indicators of nutritional and functional status respectively, and would thus, support a terminal prognosis if met.

1. The nutritional impairment associated with the adult FTT syndrome should be severe enough to impact a beneficiary's weight. It is expected that the body mass index (BMI) of beneficiaries electing the Medicare hospice benefit for the adult FTT syndrome will be below 22 kg/m² and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

BMI (kg/m²)=703 x (weight in pounds) divided by (height in inches)²

2. The disability associated with the adult FTT syndrome should be such that the individual is significantly disabled. Significant disability would be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%.

Both the beneficiary's BMI and level of disability should be determined using measurements/observations made within 6 months (180 days) of the most recent certification/recertification date. If enteral nutritional support has been instituted prior to the election of the Hospice Medicare Benefit and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification.

At the time of recertification, recumbent measurement(s) (anthropometry) such as mid-arm muscle area in cm² may be substituted for BMI with documentation as to why a BMI could not be measured. This information will be subject to review on a case-by-case basis.

In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected.

Summary of Evidence

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Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
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Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

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Reason for Proposed LCD

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Coding Information

Bill Type Codes

Code	Description
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Revenue Codes

Code	Description
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ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

1. Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the A/B HHH MAC upon request.

2. Documentation certifying terminal status must contain sufficient information to confirm terminal status upon review. Documentation meeting the criteria outlined in the Coverage Indications, Limitations and/or Medical Necessity section of this policy would support this requirement.

3. While data collection instruments such as checklists may facilitate the evaluation of nutritional impairments and disability at the time of certification/recertification, the medical record should substantiate the degree of nutritional impairment/disability noted on such instruments.

4. A current BMI determined using the beneficiary's height and weight measured:

A. within 6 months (180 days) of the most recent certification/recertification date for beneficiaries without enteral nutritional support; or,

B. at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

5. If recumbent anthropometry is substituted for BMI at recertification, the rationale should be documented.

6. A current evaluation of the beneficiary's functional status demonstrating a level of disability equivalent to that described by a Karnofsky or Palliative Performance Scale value of less than or equal to 40%, determined:

A. within a 6-month period (180 days) from the most recent certification/recertification date for beneficiaries with enteral nutritional support; or,

B. at the time of initial certification and at each subsequent recertification for beneficiaries receiving enteral nutritional support.

Sources of Information
N/A

Bibliography

Anderson F, Downing GM, Hill J, Casorso L, Lerch N. Palliative performance scale (PPS): A new tool. J Palliat Care. 1996;12(1):5-11.

Fried LP, Walston J. Frailty and failure to thrive. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG, eds. Principles of Geriatric Medicine and Gerontology. 4th ed. New York, NY: McGraw-Hill Companies; 1999:1387-1402.

Karnofsky DA, Burchenal JH. The clinical evaluation of chemotherapeutic agents in cancer. In: MacLeod CM, ed. Evaluation of Chemotherapeutic Agents. 1st ed. New York, NY: Columbia University Press; 1949:191-205.

Verdery RB. Clinical evaluation of failure to thrive in older people. Clin Geriatr Med. 1997;13(4):769-778.

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
01/04/2024	R15	Under *CMS National Coverage Policy* updated section headings and regulation descriptions. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting and punctuation errors were corrected throughout.	Provider Education/Guidance
11/11/2021	R14	Under *CMS National Coverage Policy* updated regulation descriptions and section headings. This revision is effective on 11/11/21.	Provider Education/Guidance
12/03/2020	R13	Under *CMS National Coverage Policy* added section headings to the regulations. Typographical errors were corrected throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
10/24/2019	R12	This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the *CMS National Coverage Policy* section of this LCD and placed in the related Billing and Coding: Hospice The Adult Failure To Thrive Syndrome A56679 article. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
07/04/2019	R11	All coding located in the *Coding Information* section has been moved into the related Billing and Coding: Hospice The Adult Failure To Thrive Syndrome A56679 article and removed from the LCD. All verbiage regarding billing and coding under the *Associated Information* section has been removed and is included in the related Billing and Coding: Hospice The Adult Failure To Thrive Syndrome A56679 article. Formatting, punctuation and typographical errors were corrected throughout the LCD. At this time 21^stCentury Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
06/20/2019	R10	Under *CMS National Coverage Policy* removed the first paragraph regarding quoted Internet Only Manual (IOM) text and consolidated CMS Internet-Only Manual, Pub 100-04, Medicare Claim Processing Manual, Chapter 11, §§30.2, 30.2.2, 30.3, and 30.4 regulation. Under *Bibliography* changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted and defined where appropriate throughout the LCD.	Provider Education/Guidance
05/03/2018	R9	Under CMS National Coverage Policy in the first paragraph deleted the second and third sentence. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.	Provider Education/Guidance
05/04/2017	R8	Under *CMS National Coverage Policy* Change Request 9369, Transmittal 3378, dated October 16, 2015 was deleted as the information has been manualized and the following reference was added: CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 11, §§30.2, 30.2.2, and 30.3.	Provider Education/Guidance
01/01/2017	R7	Under *CPT/HCPCS Codes* the description was revised for HCPCS code G0300. This revision is due to the 2017 Annual CPT/HCPCS Code Update and becomes effective 1/1/17.	Provider Education/Guidance Revisions Due To CPT/HCPCS Code Changes
10/01/2016	R6	Under *ICD-10 Codes That Support Medical Necessity* added ICD-10 code M62.84. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.	Provider Education/Guidance Revisions Due To ICD-10-CM Code Changes
05/05/2016	R5	Under *CMS National Coverage Policy* added verbiage related to italicized text found throughout the LCD and revised “hospice” to read “terminally ill individual” in the first citation. Section 20.2 was deleted from the following: CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 9, §§10, 20.1, 20.2.1, 40, and 80 and added “each” in the verbiage for Title XVIII of the Social Security Act, §1812 (a)(4). Under *Coverage Indications, Limitations and/or Medical Necessity* for clarification purposes, revised the last paragraph to now read, “In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. R63.4 "abnormal loss of weight" and R64 "Cachexia").” Under *Associated Information-Documentation Requirements 1.* deleted “the”. Under *Sources of Information and Basis for Decision* deleted “et al” and added author names to Anderson F, Downing GM, Hill J, Casorso L, Lerch N. Palliative performance scale (PPS): A new tool. Journal of Palliative Care. 1996;12(1):5-11. ”Et al” was deleted, an author name and page numbers were added, and the place of publication was added for the following: Fried L, Walston J. Frailty and Failure to Thrive. In: Hazzard WR, Blass JP, Ettinger WH, Ouslander J, eds. Principles of Geriatric Medicine and Gerontology. New York, NY: McGraw Hill Companies, Inc;1999:1308-1402.	Provider Education/Guidance Typographical Error Other
01/01/2016	R4	Under CMS National Coverage Policy section added CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Change Request 9369, Transmittal 3378 dated October 16, 2015. Under CPT/HCPCS Codes section added HCPCS codes G0299 and G0300.	Revisions Due To CPT/HCPCS Code Changes
10/01/2015	R3	Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.	Other (Bill type and/or revenue code removal)
10/01/2015	R2	Under CMS National Coverage Policy added citation for CMS Internet-Only Manual 100-04, Chapter 11, §30.3 and 30.4; added citation for Change Request 8877, Transmittal 3032 Dated August 22, 2014. Under Coverage Indications, Limitations and/or Medical Necessity removed the last paragraph “In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above, but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected (e.g. 783.21 "abnormal loss of weight" and 799.4 "Cachexia")”. Corrected the paragraph to read “R63.4 “abnormal loss of weight” and R64 “Cachexia” are additional secondary diagnoses which may describe the clinical circumstances of an individual beneficiary”. Under ICD-10 Codes that Support Medical Necessity added R63.4 and R64. Under Associated Information added a "Utilization Guidelines" section with manual instructions on the use of ill-defined diagnoses. The instructions are as follows: Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-10-CM Coding Guidelines or require further compliance with various ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines and Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.	Provider Education/Guidance Other (Annual Validation)
10/01/2015	R1	In CMS National Coverage Policy, added Hospice Care to citation for 42 CFR and added Title XVII- Health Insurance for the aged and disabled reference. In Coverage and Indications, Limitations and /or Medical Necessity added “have an” in the last sentence of the first paragraph. Removed in-text citations as corrections were made to the citation list. In Sources of Information and Basis for Decision, corrected all citations to AMA formatting. Moved Title XVII- Health Insurance for the aged and disabled reference to CMS National Coverage Policy.	Provider Education/Guidance Other (Annual Validation)

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Updated On	Effective Dates	Status
12/29/2023	01/04/2024 - N/A	Currently in Effect	You are here
11/03/2021	11/11/2021 - 01/03/2024	Superseded	View
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Keywords

Hospice The Adult Failure to Thrive
Adult Failure to Thrive
Failure to Thrive

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Hospice The Adult Failure To Thrive Syndrome

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