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 A56639 (Billing and Coding: Hospice Alzheimer's Disease & Related Disorders) 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.
A56639: Billing and Coding: Hospice Alzheimer's Disease & Related Disorders (Billing and Coding, effective 2025-10-01)
- Covered ICD-10-CM codes
- 10
- 1 group
- Non-covered ICD-10-CM codes
- 0
- Procedure codes listed
- 2
- Full article
- cms.gov record
| ICD-10-CM | Description (FY2027) |
|---|---|
| G30.0 | — |
| G30.1 | — |
| G30.8 | — |
| G30.9 | — |
| G31.01 | — |
| G31.1 | — |
| G31.80 | — |
| G31.85 | — |
| G31.86 | — |
| G31.87 | — |
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
Alzheimer’s Disease (AD) and related disorders may support a prognosis of 6 months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of AD are often complicated by comorbid and/or secondary conditions. Comorbid conditions affecting beneficiaries with AD are by definition distinct from the AD itself. Examples include coronary heart disease (CHD) and chronic obstructive pulmonary disease (COPD). Secondary conditions, on the other hand, are directly related to a primary condition. In the case of AD, examples include delirium and pressure ulcers. The important roles of comorbid and secondary conditions are described below in order to facilitate their recognition and assist providers in documenting their impact.
The Reisberg Functional Assessment Staging (FAST) scale has been used for many years to describe Medicare beneficiaries with AD and a prognosis of 6 months or less. The FAST scale is a 16-item scale designed to parallel the progressive activity limitations associated with AD. Stage 7 identifies the threshold of activity limitation that would support a 6-month prognosis. The FAST scale does not address the impact of comorbid and secondary conditions. These 2 variables are thus considered separately by this policy.
FAST Scale Items:
Stage #1: No difficulty, either subjectively or objectively
Stage #2: Complains of forgetting location of objects; subjective work difficulties
Stage #3: Decreased job functioning evident to coworkers; difficulty in traveling to new locations
Stage #4: Decreased ability to perform complex tasks (e.g., planning dinner for guests; handling finances)
Stage #5: Requires assistance in choosing proper clothing
Stage #6: Decreased ability to dress, bathe, and toilet independently:
· Sub-stage 6a: Difficulty putting clothing on properly
· Sub-stage 6b: Unable to bathe properly; may develop fear of bathing
· Sub-stage 6c: Inability to handle mechanics of toileting (i.e., forgets to flush, does not wipe properly)
· Sub-stage 6d: Urinary incontinence
· Sub-stage 6e: Fecal incontinence
Stage #7: Loss of speech, locomotion, and consciousness:
· Sub-stage 7a: Ability to speak limited (1 to 5 words a day)
· Sub-stage 7b: All intelligible vocabulary lost
· Sub-stage 7c: Non-ambulatory
· Sub-stage 7d: Unable to sit up independently
· Sub-stage 7e: Unable to smile
· Sub-stage 7f: Unable to hold head up
Comorbid Conditions:
The significance of a given comorbid condition is best described by defining the structural/functional impairments, together with any limitation in activity, related to the comorbid condition. For example, a beneficiary with AD and clinically significant CHD or COPD would have specific impairments of cardiorespiratory function (e.g., dyspnea, orthopnea, wheezing, chest pain), which may or may not respond or be amenable to treatment. The identified impairments in cardiorespiratory function would be associated with both specific structural impairments of the coronary arteries or bronchial tree, and may be associated with activity limitations (e.g., mobility, self-care). Ultimately, the combined effects of the AD (FAST stage 7 or beyond) and any comorbid condition should be such that most beneficiaries with AD (FAST stage 7 or beyond) and similar impairments would have a prognosis of 6 months or less.
Secondary Conditions:
AD may be complicated by secondary conditions. The significance of a given secondary condition is best described by defining the structural/functional impairments, together with any limitation in activity, related to the secondary condition. The occurrence of secondary conditions in beneficiaries with AD is facilitated by the presence of impairments in such body functions as mental functioning and movement functions. Such functional impairments contribute to the increased incidence of secondary conditions, such as delirium and pressure ulcers, observed in Medicare beneficiaries with AD. Secondary conditions themselves may be associated with a new set of structural/functional impairments that may or may not respond or be amenable to treatment. Ultimately, the combined effects of the AD (FAST stage 7 and beyond) and any secondary condition should be such that most beneficiaries with AD and similar impairments would have a prognosis of 6 months or less.
The documentation of structural/functional impairments and activity limitations facilitate the selection of intervention strategies (palliative vs. curative) and provide objective criteria for determining the effects of such interventions. The documentation of these variables is thus essential in the determination of reasonable and necessary Medicare hospice services.
Summary:
For beneficiaries with AD to be eligible for hospice the individual should have a FAST level of greater than or equal to 7 and specific comorbid or secondary conditions meeting the above criteria.
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
- 2024-02-29
- Last reviewed by the contractor
- 2024-01-24
- MCD version
- 43
- Derived from
- L31539
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 L34567 cover?
Alzheimer’s Disease (AD) and related disorders may support a prognosis of 6 months or less under many clinical scenarios. The identification of specific structural/functional impairments, together with any relevant activity limitations, should serve as the basis for palliative interventions and care planning. The structural and functional impairments associated with a primary diagnosis of AD are often complicated… 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 L34567 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 L34567?
The companion billing and coding article A56639 lists 10 ICD-10-CM codes in 1 group that support medical necessity; the first 10 appear on this page and the complete list is in the article on cms.gov.
How do I appeal a denial under LCD L34567?
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.