Patient must have 1 or 2, 3 and 4.

  1. CD4 + Count <25 cells/mm³


  2. Persistent viral load >100,000 copies/ml from two (2) or more assays at least one (1) month apart.


  3. At least (1) of the following conditions:
    1. CNS lymphoma
    2. Untreated or refractory wasting (loss of >33% lean body mass)
    3. Mycobacterium avium complex (MAC) bacteremia, untreated, refractory or treatment refused
    4. Progressive multifocal leukoencephalopathy
    5. Systemic lymphoma
    6. Refractory visceral Kaposi’s sarcoma
    7. Renal failure in the absence of dialysis
    8. Refractory cryptosporidium infection
    9. Refractory toxoplasmosis
    10. Treatment resistant symptomatic dysrythmias
    11. History of unexpected or cardiac related syncope
    12. CVA secondary to cardiac embolism
    13. History of cardiac arrest or resuscitation


  4. PPS of <50%
    1. Requires considerable assistance and frequent medical care
    2. Activity limited mostly to bed and chair

Supporting documentation:

  • Chronic persistent diarrhea for one year
  • Persistent serum albumin <2.5
  • Concomitant active substance abuse
In the absence of one or more of the above findings, rapid decline or comorbidities may also support eligibility for hospice care. 

Other guides:
CHF/Heart Disease
COPD/Pulmonary Disease
CVA /Stroke/Coma
Huntington’s Disease
Liver Disease
Neurological Diseases 
      ALS (Amyotrophic Lateral Sclerosis)
      Muscular Dystrophy
      Myasthenia Gravis
      MS (Multiple Sclerosis)
Renal Failure, Chronic or Acute

Assessment Tools
Palliative Performance Scale (PPS)
New York Heart Association (NYHA) Functional Classes
Functional Assessment Staging (FAST) Scale

Frequent Co-Morbidity documentation requirements
Cachexia or Protein Calorie Malnutrition

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