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. Treatment resistant symptomatic dysrythmias
    10. History of unexpected or cardiac related syncope
    11. CVA secondary to cardiac embolism
    12. 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

See another guide:
CVA (Stroke)/Coma
Heart Disease/CHF (Congestive Heart Failure)
Huntington’s Disease
Liver Disease
Neurological Diseases (see list below)
      ALS (Amyotrophic Lateral Sclerosis)
      Muscular Dystrophy
      Myasthenia Gravis
      MS (Multiple Sclerosis)
Pulmonary Disease/COPD (Chronic Obstructive Pulmonary Disease)
Renal (Kidney) Failure

Frequent Co-Morbidity documentation requirements
Cachexia/Protein Calorie Malnutrition (Weight Loss)

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

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