Where this LCD applies
Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.
| Contract | Contractor | Type | States |
|---|---|---|---|
| 11004 | Palmetto GBA | A and B and HHH MAC | AL AR FL GA IL IN KY LA MS NC NM OH OK SC TN TX |
Billing and coding: diagnoses and procedure codes
Since 2019 the codes live in the companion article rather than the LCD. Billing and Coding A56669 (Billing and Coding: Hospice - Liver Disease) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.
A56669: Billing and Coding: Hospice - Liver Disease (Billing and Coding, effective 2024-08-01)
- Covered ICD-10-CM codes
- 44
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| C22.0 | — |
| C22.2 | — |
| C22.3 | — |
| C22.4 | — |
| C22.7 | — |
| C22.8 | — |
| K70.2 | — |
| K70.30 | — |
| K70.31 | — |
| K70.41 | — |
| K71.0 | — |
| K71.10 | — |
| K71.11 | — |
| K71.2 | — |
| K71.3 | — |
| K71.4 | — |
| K71.50 | — |
| K71.51 | — |
| K71.6 | — |
| K71.7 | — |
| K71.8 | — |
| K71.9 | — |
| K72.01 | — |
| K72.11 | — |
Procedure codes: G0299 (Direct Skilled Nursing Services Of A Registered Nurse (Rn) In The Home Health Or Hospice Setting, Each 15 Minutes), G0300 (Direct Skilled Nursing Services Of A Licensed Practical Nurse (Lpn) In The Home Health Or Hospice Setting, Each 15 Minutes).
Coverage indications, limitations and medical necessity
Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this A/B HHH Medicare Administrative Contractor (MAC) has established medical criteria for determining prognosis for non-cancer diagnoses. These criteria form a reasonable approach to the determination of life expectancy based on available research and may be revised as more research is available. Coverage of hospice care for patients not meeting the criteria in this policy may be denied. However, some patients may not meet the criteria, yet still be appropriate for hospice care because of other comorbidities or rapid decline. Coverage for these patients may be approved on an individual consideration basis.
Patients will be considered to be in the terminal stage of liver disease (life expectancy of 6 months or less) if they meet the following criteria (1 and 2 must be present; factors from 3 will lend supporting documentation):
1. The patient should show both a and b:
a. Prothrombin time prolonged more than 5 seconds over control, or International Normalized Ratio (INR)> 1.5
b. Serum albumin 2. End stage liver disease is present, and the patient shows at least one of the following:
a. Ascites, refractory to treatment or patient non-compliance
b. Spontaneous bacterial peritonitis
c. Hepatorenal syndrome (elevated creatinine and blood urea nitrogen (BUN) with oliguria ( d. Hepatic encephalopathy, refractory to treatment, or patient non-compliance
e. Recurrent variceal bleeding, despite intensive therapy
3. Documentation of the following factors will support eligibility for hospice care:
a. Progressive malnutrition
b. Muscle wasting with reduced strength and endurance
c. Continued active alcoholism (>80gm ethanol/day)
d. Hepatocellular carcinoma
e. Hepatitis B virus surface antigen (HBsAg) positivity
f. Hepatitis C refractory to interferon treatment.
Patients awaiting liver transplant who otherwise fit the above criteria may be certified for the Medicare hospice benefit, but if a donor organ is procured, the patient must be discharged from hospice.
Summary of evidence (opening)
N/A
the full summary and analysis of evidence are in the CMS record.
Dates, lineage and related policies
- Original determination effective
- 2015-10-01
- Current revision effective
- 2024-08-01
- Last reviewed by the contractor
- 2024-06-21
- MCD version
- 47
- Derived from
- L31536
Other related documents: A53056 (Article).
Using this policy on a claim
Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Palmetto GBA hub lists every other active policy from the same contractor.
Frequently asked questions
What does LCD L34544 cover?
Medicare coverage of hospice care depends upon a physician’s certification of an individual’s prognosis of a life expectancy of six months or less if the terminal illness runs its normal course. Recognizing that determination of life expectancy during the course of a terminal illness is difficult, this A/B HHH Medicare Administrative Contractor (MAC) has established medical criteria for determining prognosis for… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.
Which states does LCD L34544 apply to?
Palmetto GBA applies it to Medicare claims in AL, AR, FL, GA, IL, IN, KY, LA, MS, NC, NM, OH, OK, SC, TN, TX. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.
Which diagnosis codes support medical necessity under LCD L34544?
The companion billing and coding article A56669 lists 44 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34544?
The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database, current LCD exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
- Medicare Coverage Database, current Billing and Coding Articles exportVersion MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
- ICD-10-CM FY2027 code descriptionsVersion FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…
Disclaimer
The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.