Indicators and limitations of coverage and/or necessity

Medicare/Medicaid Qualifications

Criteria below must be present at the time of initial certification or recertification for hospice. Alzheimer’s disease and related disorders may support a prognosis of six months or less under many clinical scenarios.

The structural and functional impairments associated with a primary diagnosis of Alzheimer’s disease are often complicated by co-morbid and/or secondary conditions. Co-morbid conditions affecting beneficiaries with Alzheimer’s disease are by definition distinct from the Alzheimer’s disease itself – examples include coronary heard disease (CHD) and chronic obstructive pulmonary disease (COPD).

Secondary conditions, on the other hand, are directly related to a primary condition – in the case of Alzheimer’s disease examples include delirium and pressure ulcers. The Reisberg Functional Assessment Staging (FAST) Scale has been used for many years to describe Medicare beneficiaries with Alzheimer’s disease and a prognosis of six months or less.

The FAST Scale is a 16-item scale designed to parallel the progressive activity limitations associated with Alzheimer’s disease. Stage 7 identifies the threshold of activity limitation that would support six-month prognosis; however all sub stage FAST Scale indicators under stage 7 must be present. The FAST Scale does not address the impact of co-morbid or secondary conditions. The presence of secondary conditions is thus considered separately by this policy and (1) must be present; factors from (2) will add supporting documentation. The FAST Scale is designed to parallel the progressive activity.

1. To be eligible for hospice beneficiaries with Alzheimer’s disease must have a FAST scale of greater than or equal to 7. FAST Scale items:

Stage 1: No difficulty, either subjectively or objectively

Stage 2: Complains of forgetting location of objects; subjective work difficulties

Stage 3: Decrease job functioning evident to coworkers; difficulty in traveling to new locations

Stage 4: Decreased ability to perform complex tasks (e.g., planning dinner for guests, handling finances)

Stage 5: Requires assistance in choosing proper clothing

Stage 6: Decreased ability to dress, bathe and toilet independently

Sub Stage 6a: Difficulty putting clothing on properly

Sub Stage 6b: Unable to bathe properly; may develop fear of bathing

Sub Stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)

Sub Stage 6d: Urinary incontinence

Sub Stage 6e: Fecal incontinence

Stage 7: Loss of speech, locomotion and consciousness

Sub Stage 7a: Ability to speak limited (1 to 5 words a day)

Sub Stage 7b: All intelligible vocabulary lost

Sub Stage 7c: Non-ambulatory

Sub Stage 7d: Unable to sit up independently

Sub Stage 7e: Unable to smile

Sub Stage 7f: Unable to hold head up

2. Documentation of specific secondary conditions (i.e. Pressure ulcers, UTI, dysphagia, aspiration pneumonia) related to Alzheimer’s disease will support eligibility for hospice care.