LCD L34558: Hospice The Adult Failure To Thrive Syndrome

The adult failure to thrive (FTT) syndrome is characterized by unexplained weight loss, malnutrition and disability. The syndrome has been associated with multiple primary conditions (e.g., infections and malignancies), but always includes 2 defining clinical elements, namely nutritional impairment and disability. The nutritional impairment and disability associated with the adult FTT syndrome may be severe enough to have an impact on the patient’s short-term survival.

The adult FTT syndrome may manifest as an irreversible progression in the patient’s nutritional impairment/disability despite a trial of therapy (i.e., treatment intended to affect the primary condition responsible for the patient’s clinical presentation). The presence of comorbid conditions may hasten the patient’s clinical progression and as such should be identified and addressed. This hospice policy addresses those cases where reversible causes of severe nutritional impairment and disability (i.e., the adult FTT syndrome) have been excluded.

The Medicare hospice benefit is predicated upon physician-certification that an individual entitled to Part A of Medicare is terminally ill. An individual is considered to be terminally ill if the individual has a medical prognosis that his or her life expectancy is 6 months or less if the terminal illness runs its normal course. The medical criteria listed below would support a terminal prognosis for individuals with the adult FTT syndrome. Medical criteria 1 and 2 are important indicators of nutritional and functional status respectively, and would thus, support a terminal prognosis if met.

1. The nutritional impairment associated with the adult FTT syndrome should be severe enough to impact a beneficiary's weight. It is expected that the body mass index (BMI) of beneficiaries electing the Medicare hospice benefit for the adult FTT syndrome will be below 22 kg/m 2 and that the patient is either declining enteral/parenteral nutritional support or has not responded to such nutritional support, despite an adequate caloric intake.

BMI (kg/m 2 )=703 x (weight in pounds) divided by (height in inches) 2

2. The disability associated with the adult FTT syndrome should be such that the individual is significantly disabled. Significant disability would be demonstrated by a Karnofsky or Palliative Performance Scale value less than or equal to 40%.

Both the beneficiary's BMI and level of disability should be determined using measurements/observations made within 6 months (180 days) of the most recent certification/recertification date. If enteral nutritional support has been instituted prior to the election of the Hospice Medicare Benefit and will be continued, the BMI and level of disability should be determined using measurements/observations made at the time of the initial certification and at each subsequent recertification.

At the time of recertification, recumbent measurement(s) (anthropometry) such as mid-arm muscle area in cm 2 may be substituted for BMI with documentation as to why a BMI could not be measured. This information will be subject to review on a case-by-case basis.

In the event a beneficiary presenting with a nutritional impairment and disability does not meet the medical criteria listed above but is still thought to be eligible for the Medicare Hospice Benefit, an alternate diagnosis that best describes the clinical circumstances of the individual beneficiary should be selected.

N/A