Indicators and limitations of coverage and/or necessity

Medicare Qualifications

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of heart disease. Medical criteria 1 and 2 are important indications of the severity of heart disease and would thus support a terminal prognosis if met:

1. At the time of initial certification or recertification
2. Patient is already optimally treated with diuretics and vasodilators, which may include angiotensin-converting enzymes (ACE) inhibitors or the combination of hydralazine and nitrates. If side effects, such as hypotension or hyperkalemia, prohibit the use of ACE inhibitors or the combination of hydralazine and nitrates, this must be document in the medical records

OR

1. Patients having angina pectoris, at rest, resistant to standard nitrate therapy and are either not candidates or decline invasive procedures
2. The patient has significant symptoms of recurrent congestive hear failure (CHF) at rest, and is classified as a New York Heart Association (NHYA) Class IV:
3. Unable to carry on any physical activity without symptoms
4. Symptoms are present even at rest
5. If any physical activity is undertaken, symptoms are increased
6. Documentation of the following factors may provide additional support for end stage heart disease:
7. Treatment resistant symptomatic supraventricular or ventricular arrhythmias
8. History of cardiac arrest or resuscitation
9. History of unexplained syncope
10. Brain embolism of cardiac origin
11. Concomitant HIV disease
12. Documentation of ejection fraction of 20% or less

Medicaid Qualifications

Medical criteria (i) and (ii) must be present as they are important indicators of the severity of heart disease and would thus support a terminal prognosis if met.

1. When the recipient is approved or recertified the:
2. Patient is already optimally treated with diuretics and vasodilators, which may include angiotensin-converting enzymes (ACE) inhibitors or the combination of hydralazine and nitrates. If side effects, such as hypotension or hyperkalemia, or evidence of treatment failure prohibit the use of ACE inhibitors or the combination of hydralazine and nitrates, or patient voluntary declines the treatment the documentation must be present in the medical records or with lab results and medical records submitted upon request.
3. Patient has angina pectoris, at rest, resistant to standard nitrate therapy and are either not candidates or decline invasive procedures. This must be supported by documentation contained in the medical record.
4. The patient has significant symptoms of recurrent congestive heart (CHF) at rest, and is classified as a New York Heart Association Class IV:
5. Unable to carry on any physical activity without symptoms
6. Symptoms are present even at rest
7. If any physical activity is undertaken, symptoms are increased

iii. Documentation of the following factors may provide additional support for end stage heart disease:

1. Treatment resistant symptomatic supraventricular or ventricular arrhythmias
2. History of cardiac arrest or resuscitation
3. History of unexplained syncope
4. Brain embolism of cardiac origin
5. Concomitant HIV disease
6. Documentation of ejection fraction of 20% or less