Indicators and limitations of coverage and/or necessity

Medicare/Medicaid Qualifications

The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of stroke. Medical criteria 1 and 2 are important indicators of functional and nutritional status respectively, and would thus support a terminal prognosis if met.
1. A Palliative Performance Scale (PPS) of greater than or equal to 40
a. Degree of ambulation
• Mainly in bed
b. Activity/extent of disease
• Unable to do work; extensive disease
c. Ability to do self-care
• Mainly assistance
d. Food/fluid intake
• Normal to reduced
e. State of consciousness
• Either fully conscious or drowsy/confused
2. Inability to maintain hydration and caloric intake with one of the following:
a. Weight loss >10% during previous six months (previous 3 months for Medicaid)
b. Weight loss >7.5% in previous three months (previous six weeks for Medicaid)
c. Serum albumin <2.5 gm/dld Current history of pulmonary aspiration without effective response to speech language pathology interventions to improve dysphagia and decrease aspiration events. Calorie counts documenting inadequate caloric/fluid intake if a beneficiary does not meet both medical criteria 1 and 2 the documentation should describe a relevant comorbidity and/or rapid decline. The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology): 1. Comatose patients with any 3 of the following on day three of coma: a. Abnormal brain stem response b. Absent verbal response c. Absent withdrawal response to pain d. Serum creatinine >1.5 mg/dl