Clinical UM Guideline

This document addresses home hospice care. Home hospice care refers to a comprehensive home-based, interdisciplinary, palliative care program for individuals with a serious medical illness who shift their focus from trying to cure or reverse their disease to maximizing quality of life and have a prognosis of 6 months or less if the disease follows its natural course.

Note: Please see the following related documents for additional information:

• CG-MED-23 Home Health
• CG-REHAB-07 Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 Private Duty Nursing in the Home Setting
• CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

Note: The Clinical Indications in this document apply to hospice care delivered in the home setting only.

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

1. Home hospice services are considered medically necessary when both of the following criteria (A and B) below are met:
   1. The individual requires hospice care, as evidenced by meeting both of the following criteria (1 and 2):
      1. The individual is terminally ill (for example, life expectancy is 6 months or less if illness runs its normal course) as certified by two practitioners who are caring for the individual; and
      2. The individual requires the management of symptoms and other care needs related to a terminal illness.
         and
   2. The individual requires either of the following:
      1. Routine home hospice services: Services required for less than 8 hours of predominantly nursing care during a 24-hour day, which begins and ends at midnight; or
      2. Continuous home care services: Services required when both of the following criteria (a and b) are met:
         1. The individual requires a minimum of 8 hours of nursing, hospice aide, or homemaker care during a 24-hour day*, which begins and ends at midnight.
            and
         2. The continuous home care services are provided only during a period of crisis** as necessary to maintain an individual at home.
2. Initial Authorization
   1. Home hospice services are considered medically necessary for an initial authorization period of up to 90 days when all applicable Medically Necessary criteria in Section I above are met, including documentation supporting that the individual has a life expectancy of six months or less if the illness runs its normal course.
3. Continued Authorization (Recertification)
   1. Continued authorization of home hospice services beyond the initial authorization period requires recertification and is considered medically necessary when documentation demonstrates that the individual continues to meet hospice eligibility criteria.
      1. Recertification is considered medically necessary when criteria a and b below are met:
         1. The individual continues to have a reasonable expectation of a life expectancy of six months or less if the illness runs its normal course; and
         2. One of the following criteria is met:
            1. The individual demonstrates ongoing clinical decline, continued symptom burden, or disease progression, or
            2. The individual has stabilized or shown limited improvement but with a reasonable expectation of continued decline consistent with terminal status.
   2. Recertification Durations:
      1. After the end of the initial 90-day authorization period has expired, a second 90-day authorization period is considered medically necessary when continued terminal status is documented.
      2. For subsequent authorization periods, up to 60 days per authorization period are considered medically necessary when continued terminal status is documented.

Note: Individuals whose hospice services are discontinued due to improvement may be considered for reauthorization if subsequent clinical decline again supports hospice eligibility.

*This care does not need to be uninterrupted, e.g., 4 hours could be in the morning and another 4 hours in the evening. In addition to the 8-hour minimum, the services provided must be predominantly nursing care, provided by either a registered nurse (RN), a licensed practical nurse (LPN), or a licensed vocational nurse (LVN).

**A period of crisis is a period in which an individual requires hospice care to achieve palliation or management of acute medical symptoms. If an individual’s caregiver has been providing a skilled level of care for the individual and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver.

Not Medically Necessary:

1. Home hospice services are considered not medically necessary when the medically necessary criteria above have not been met.
2. Continued home hospice services are considered not medically necessary when:
   1. The individual’s condition has improved or stabilized such that they no longer have a reasonable expectation of a life expectancy of six months or less, and
   2. The improvement is expected to be sustained outside the hospice setting.

This document describes clinical studies and expert recommendations, and explains when home hospice services are appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Home hospice services provide care for people who are terminally ill, meaning they are expected to live six months or less if the illness runs its normal course. This care helps people remain comfortable at home and focuses on support rather than curing the illness. Hospice services can include visits from nurses, doctors, social workers, aides, and others who help with medical, emotional, spiritual, and practical needs. Services may be offered for part of the day or up to 24 hours during a crisis. Home hospice care may be appropriate when the person needs help managing symptoms of a terminal illness and is no longer seeking treatment to cure their disease.

What the Studies Show

Hospice care focuses on comfort, not cure, and aims to improve quality of life for people nearing the end of life. It also supports family members during the illness and after death. The care is often provided in the home but can also be offered in facilities such as nursing homes, hospitals and dedicated hospice facilities. According to national health organizations, hospice helps people with serious illnesses by managing pain and other symptoms for conditions such as cancer, dementia, heart failure, or advanced lung disease. Hospice programs use a team approach. This team may include nurses, doctors, social workers, chaplains, aides, volunteers, and grief counselors. Their goal is to support both the person receiving care and the people taking care of them.

There are four levels of hospice care. Routine home care is the most common and is provided when a person’s condition is stable. Continuous home care may be needed in times of crisis and includes at least eight hours of nursing care per day to help with severe symptoms. Respite care offers short-term relief for caregivers and can take place in a facility. General inpatient care may be needed for people whose symptoms cannot be managed at home and need around-the-clock care in a hospital or hospice facility.

The use of hospice care is based on the predictions of life expectancy that are made by the health care professionals taking care of the person. Because predicting the future is not an exact science, it is possible to need hospice longer than six months. Once someone is in hospice, looking at how their disease progresses may help doctors make better predictions. In some cases, people who are admitted to hospice may decline in a way that changes the predictions. When this happens hospice may no longer be needed, or the person may need hospice later when their condition gets worse.

Despite growth in hospice use, studies show that there are racial disparities. One study found that Black individuals were less likely to receive hospice care than white individuals, especially when the cause of death was not cancer. They were also more likely to visit the emergency department or be hospitalized near the end of life. Experts say better outreach, communication, and education are needed to ensure more people have access to hospice services, regardless of their background.

When is Home Hospice Clinically Appropriate?

Home hospice services may be appropriate in these situations:

• The person has a serious illness that is not expected to improve, with a life expectancy of six months or less if the illness runs its usual course; and
• The person needs services to manage symptoms of their illness or related conditions; and either
• Routine home hospice is needed for less than eight hours of mostly nursing care during a 24-hour period; or
• Continuous home care is needed for at least eight hours in a 24-hour period, mostly from nurses, during a time of crisis to help the person stay at home. Care does not have to be nonstop but must total at least eight hours per day and be mostly nursing care. A crisis is when severe symptoms or the loss of a skilled caregiver require(s) nursing help to manage symptoms.

When is this not Clinically Appropriate?

Home hospice services are not appropriate if the person does not meet the above criteria.

(Return to Description)

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Summary

Home hospice services are designed for individuals with a terminal illness and a life expectancy of six months or less, aiming to provide comfort and support rather than curative treatment. Care is delivered through an interdisciplinary team including nurses, physicians, social workers, chaplains, and aides, and focuses on physical, emotional, and spiritual needs. There are four levels of care: routine home care, continuous home care during crises, inpatient respite care for caregiver relief, and general inpatient care for severe symptoms that cannot be managed at home. Clinical appropriateness is based on the individual’s prognosis and need for symptom management, with specific criteria for nursing care hours and crisis situations. The use of hospice services are recommended by several respected national organizations, including the National Institute on Aging (NIA), the Centers for Medicare and Medicaid Services (CMS), and the National Hospice and Palliative Care Organization (NHPCA). Despite proven benefits, such as improved quality of life and support for families, studies show racial disparities in hospice access, especially among non-cancer patients, highlighting the need for better communication, education, and inclusive outreach strategies.

Discussion

Hospice Care Services

Hospice care services are generally provided when an individual is estimated to have 6 months or less to live. According to the American Cancer Society (ACS), hospice services provide individuals with comfort and support care during the last phases of an incurable disease so that they may live as fully and comfortably as possible. In their review of comprehensive hospice care, Fine and colleagues (2006) point out that the focus of hospice treatment is palliative, not curative, and that “hospice care is based on a biopsychosocial model rather than a disease model of care”. With the understanding that death is an inevitable result of living, hospice care emphasizes “quality of life at the end of life and supportive care rather than a cure or life prolongation”.

According to the NIA:

Hospice care is a service for people with serious illnesses who choose not to get (or continue) treatment to cure or control their illness. … Hospice aims to provide comfort and peace to help improve quality of life for the person nearing death. It also helps family members cope with their loved one’s illness and can also provide support to the family after the person dies, including help with grieving, sometimes called bereavement care …

Many people with a serious illness use hospice care. A serious illness may be defined as a disease or condition with a high risk of death or one that negatively affects a person’s quality of life or ability to perform daily tasks. It may cause symptoms or have treatments that affect daily life and lead to caregiver stress. Examples of serious illnesses include dementia, cancer, heart failure, and chronic obstructive lung disease (NIA, 2021).

According to Meier (2023), hospice programs generally consider the individual and the individual’s family or loved ones as the recipients of care. Hospice care services can be provided to individuals of all ages and generally involve an interdisciplinary team. The hospice interdisciplinary team consists of specially trained clinicians and support staff whose goals are to ensure that the individual and their families or loved ones are provided holistic care. The interdisciplinary team may include any of the following:

• Registered hospice nurse who is responsible for skilled nursing care and the coordination of other members of the interdisciplinary hospice team.
• Hospice physician who fulfills a medical and administrative role and is often board-certified in the specialty of palliative and hospice medicine. The hospice physician may also act as a liaison to the attending clinicians and assist with the management of the individual’s symptoms.
• Primary attending physician (as well as the referring physician) who helps guide the individual’s care after the referral to hospice care is made.
• Social worker who provides psychosocial (e.g., nutrition, transportation, housing and family caregiver) support for the individual and the individual’s families and loved ones. This support may also include counseling, and help with anticipatory grief, bereavement, burial/funeral planning and referrals to other support systems.
• Chaplain may oversee the spiritual needs of the individual and the individual’s families and loved ones.
• Home health aides and other direct care workers may provide assistance to the individual and the individual’s caregivers in the home, including food preparation, shopping and personal care.
• Bereavement counselors may provide support to the bereaved family members and loved ones of the hospice individual.
• Community volunteers may provide extra support for the individuals, their families and others who are close to the individuals, providing services such as reading to and visiting with the individual, as well as assisting with errands.

Levels of Hospice Care

The CMS’s Medicare Benefit Policy Manual Chapter 9 Coverage of Hospice Services Under Hospital Insurance has designated four levels of hospice care, each focusing on the specific needs of the person receiving care:

• Routine Home Care (RHC) is the most common level of hospice care. With this type of care, an individual has chosen to receive hospice care at their residence. The individual is stable, can control their symptoms and does not require continuous or inpatient hospice care.
• Continuous Home Care (CHC) is hospice care that is provided for between eight and 24 hours a day to manage acute medical symptoms and pain. CHC services consist primarily of nursing care, supplemented with caregiver and/or hospice aide services with the goal of maintaining the terminally ill individual at home during a pain or symptom crisis.
• Inpatient Respite Care (IRC, also referred to as Respite Care) provides temporary relief to the individual’s primary caregiver. Respite care may be provided in a hospital, hospice facility, or a long-term care facility with 24-hour nursing personnel present.
• General Inpatient Care (GIP) is provided to cover all aspects of the individual’s care related to the terminal illness, including all services delivered by the interdisciplinary hospice team, medication, supplies and medical equipment. This includes care that is provided for acute symptom or pain management that cannot plausibly be provided in another setting. GIP may be provided in a hospice inpatient facility, Medicare certified hospital, or nursing facility with a registered nursing staff available 24 hours a day to provide direct patient care (CMS, 2024; NHPCO, 2024).

Location of Hospice Care

Most often hospice care is provided in the place the individual receiving hospice care considers home. In addition to private residences, hospice care may be provided in nursing homes, assisted living facilities, and residential facilities. Hospice care may also be provided in freestanding hospice facilities and hospitals. The Clinical Indications in this document apply only to hospice care delivered in the home setting.

Home Hospice Care

The National Association for Home Care & Hospice (NAHC), and the National Alliance for Care at Home (NACH) encourages hospice providers to “promote inclusivity in the community by ensuring all people regardless of race, ethnicity, color, religion, gender, disability, sexual orientation, age, disease, or other characteristics have access to high-quality, end-of-life care”.

In spite of the increased utilization of hospice services in recent decades, racial disparities in the use of hospice care services have been identified. According to the National Hospice and Palliative Care Organization (NHPCO) 2024 Facts and Figures Report, during the 2022 calendar year, hospice utilization increased across all racial and ethnic groups of Medicare decedents. Although no group returned to pre-COVID-19 levels; use was highest among White beneficiaries (51.6%) and lower among Hispanic (38.3%), Asian American (38.1%), Black (37.4%), and North American Native (37.1%) beneficiaries. The principal hospice diagnosis, defined as the condition most contributing to a patient’s terminal prognosis, was most commonly Alzheimer’s disease and other nervous system or organic psychotic disorders, accounting for 25% of hospice diagnoses, followed by cancer and circulatory diseases. Combined, these three diagnostic categories represent nearly three-fourths of all hospice beneficiary diagnoses (NHPCO, 2024).

In a population-based cohort study, Ornstein and colleagues (2020) used Medicare claims data to examine the utilization of hospice care amongst individuals who expired between January 1, 2013, and December 31, 2015, due to natural causes and excluding sudden death. Multivariable logistic regression models were used to explore racial and regional differences in end-of-life outcomes and in stroke mortality. The researchers found that amongst the 1212 fee-for service Medicare beneficiaries who utilized hospice care 3 or more days during the last 6 months of life, 34.9% of black individuals used hospice care compared to 46.2% by white individuals. After stratification by cause of death, substantial racial differences in treatment intensity and service use were found among individuals who died of cardiovascular disease but not among individuals who died of cancer. In analyses adjusted for cause of death (dementia, cardiovascular disease, cancer, and other) and clinical and demographic variables, black individuals were significantly less likely to use 3 or more days of hospice (odds ratio [OR], 0.72; 95% confidence interval [CI], 0.54-0.96) and were more likely to have multiple emergency department visits (OR, 1.35; 95% CI, 1.01-1.80) and hospitalizations (OR, 1.39; 95% CI, 1.02-1.89) and undergo intensive treatment (OR, 1.94; 95% CI, 1.40-2.70) in the last 6 months of life compared with white individuals. The study also demonstrated that individuals without cancer were far less likely to use hospice care compared to individuals with a cancer-related cause of death. The authors concluded that in spite of the increased use of hospice care in recent decades, racial disparities in the use of hospice remain, especially for noncancer deaths. The authors concluded that:

Reducing the stigma of hospice use through education and community outreach is critical. In particular, reducing disparities in hospice use in populations with noncancer causes of death will require improved prognostication, better patient-clinician communication, and rethinking current hospice outreach and enrollment practices (Ornstein, 2020).

Determining Terminal Prognosis

Prognostication among palliative medicine specialists and other groups of physicians remains very inexact with inaccuracies being common. A large metanalysis of prognostication research demonstrated that among 8,338 prognostic estimates the variation in accuracy between the studies was wide and significant (range 23% to 78%). While there was correlation that continued estimates over time became more accurate, particularly amongst palliative medicine specialists using prognostic tools, the findings were not statistically significant (p = 0.74) (White, 2016).

With the vast majority of hospice patients receiving services through Medicare, the Medicare Local Coverage Determinations (LCD) for hospice eligibility have been developed and revised in conjunction with a Medical Directors’ Hospice Workgroup, and within the hospice industry serves as the general guidance and the standard of care for determining a six month prognosis and continued need for hospice care. (CMS LCD 34538).

Peer Reviewed Publications:

1. Fine PG, Davis D. Hospice: comprehensive care at the end of life. Anesthesiology Clin N Am. 2006; 24(1):181-204.
2. Ornstein KA, Roth DL, Huang J, et al. Evaluation of racial disparities in hospice use and end-of-life treatment intensity in the REGARDS Cohort. JAMA Netw Open. 2020; 3(8): e2014639.
3. White N, Reid F, Harris A, et al. A systematic review of predictions of survival in palliative care: how Accurate are clinicians and who are the experts? PLoS One. 2016; 11(8): e0161407.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 9 - Coverage of hospice services under hospital insurance. Rev.13133, Issue date 03-20-2025. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c09.pdf. Accessed on December 14, 2025.
2. Centers for Medicare and Medicaid Services. Medicare Coverage Database. Local Coverage Determination (LCD). Hospice Determining Terminal Status (L34538). Rev 08/07/2025. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34538. Accessed on January 21, 2026.
3. Meier DE, McCormick E, Lagman RL. UpToDate. Hospice: Philosophy of care and appropriate utilization in the United States. Last updated September 30, 2025. Available at: https://www.uptodate.com/contents/hospice-philosophy-of-care-and-appropriate-utilization-in-the-united-states/print. Accessed on December 14, 2025.
4. NHPCO. NHPCO facts and figures (2024). Available at: https://www.nhpco.org/wp-content/uploads/NHPCO-Facts-Figures-2024.pdf. Accessed on December 14, 2025.
5. National Institute on Aging (NIA). Frequently asked questions about hospice care. Reviewed February 8, 2021. Available at: https://www.nia.nih.gov/health/hospice-and-palliative-care/frequently-asked-questions-about-hospice-care. Accessed on December 14, 2025.
6. NCCN Clinical Practice Guidelines in Oncology™ ^© 2026. National Comprehensive Cancer Network, Inc. Palliative care V1.2026. Revised October 27, 2025. For additional information visit the NCCN website: http://www.nccn.org/. Accessed on December 14, 2025.

1. American Cancer Society. What is hospice care? Last revised May 31, 2024. Available at: https://www.cancer.org/cancer/end-of-life-care/hospice-care/what-is-hospice-care.html#:~:text=Hospice%20care%20can%20be%20started,to%20know%20all%20your%20options. Accessed on December 14,2025.

Home Hospice

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Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.