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Supportive Care
Policy Number:
MM.12.026
Line(s) of Business:
HMO; PPO
Section:
Miscellaneous
Place(s) of Service:
Home
Original Effective Date:
01/01/2017
Current Effective Date:
01/01/2017
I. Description
Supportive Care is HMSA’s palliative care benefit. The goal for this benefit is to improve the quality
of life of patients who have a serious or life-threatening disease. Typical goals of care would be to
prevent or treat symptoms of a disease, side effects caused by treatment of a disease, and
psychological, social, and spiritual problems related to a disease or its treatment.
Under the supportive care benefit, an HMSA member receives comprehensive clinical and psychosocial support while maintaining their usual care. Typically, supportive care includes skilled
nursing, case management, psycho-social support, personal care aid and spiritual support.
Additionally, most durable medical equipment and comfort medications related to the supportive
care diagnosis are covered. Supportive care providers are available by phone or in-person 24 hours
a day, 7 days a week.
II. Criteria/Guidelines
Members qualify for supportive care services (subject to Limitations and Administrative Guidelines)
when all of the following criteria are met:
A. The patient has a qualifying diagnosis that is serious, advanced, and active.
B. The patient has a performance status that falls within one of the following ranges (see the
Appendix for details on the performance status scales):
1. Palliative Performance Scale (PPS) score ≤ 60%; or
2. Eastern Cooperative Oncology Group (ECOG) score ≥ 2.
C. The patient has the indications described below for their specific diagnosis:
1. Cancer of stage 3 or 4.
2. Heart Disease:
a. Congestive Heart Failure (CHF) New York Heart Association (NYHA) Class IV; or
b. CHF NYHA Class III and one or more hospitalizations or two or more emergency
department visits related to the underlying heart condition in the past six months.
3. Advanced pulmonary disease, as evidenced by dyspnea at rest, little or no response to
maximal medical therapy, hypoxemia at rest (on room air) and hypercapnia, increasing visits
(two or more) to the emergency department or hospitalizations for pulmonary infections
and/or respiratory failure or increasing physician visits (three or more) within the past six
months. Additional supporting information may include:
a. Cor pulmonale;
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b. Unintentional weight loss (>10% weight loss over the preceding six months);
c. Resting tachycardia >100/min.
5. Other diagnoses which are advanced, active, and serious in a patient with reduced
functional capacity will be considered on a case-by-case basis.
III. Limitations
Supportive care services are limited to 90 days per rolling 12-month period. The patient may
suspend or decline supportive care services at any time. Supportive care services are automatically
suspended when a member is admitted to a hospital or SNF.
IV. Administrative Guidelines
A. Precertification is not required but members must be registered in order to receive benefits.
HMSA reserves the right to perform concurrent and/or retrospective review to validate that
services rendered met clinical and/or payment determination criteria. Supporting
documentation must be kept in the patient’s medical records and made available upon request.
B. For claims filing instructions, see Billing Instructions and Code Information.
C. Supportive care services may be requested and approved by an HMSA participating or nonparticipating provider.
D. Disease modifying therapies must be provided by HMSA participating providers in accordance
with approved HMSA medical and payment policies. Non-participating providers will be
considered on a case-by-case basis.
E. Supportive care services must be provided by a Medicare-certified hospice licensed in the state
of Hawaii. The HMSA member has the final determination of the supportive care provider.
V. Important Reminder
The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not
intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is
intended to discourage or prohibit providing other medical advice or treatment deemed
appropriate by the treating physician.
Benefit determinations are subject to applicable member contract language. To the extent there
are any conflicts between these guidelines and the contract language, the contract language will
control.
This Medical Policy has been developed through consideration of the medical necessity criteria
under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E-1.4),
generally accepted standards of medical practice and review of medical literature and government
approval status. HMSA has determined that services not covered under this Medical Policy will not
be medically necessary under Hawaii law in most cases. If a treating physician disagrees with
HMSA’s determination as to medical necessity in a given case, the physician may request that
HMSA reconsider the application of the medical necessity criteria to the case at issue in light of any
supporting documentation.
2
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VI. References
1. Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern
Cooperative Oncology Group. Am J Clin Oncol. 1982; 5:649-655.
2. Palliative Performance Scale PPSv2. Victoria Hospice Society. Available at:
http://palliative.info/resource_material/PPSv2.pdf. Accessed May 25, 2016.
VII. Appendix
Table 1: Palliative Performance Scale version 2 (PPSv2)
PPS
Level
100%
Ambulation
90%
Full
80%
Full
70%
Reduced
60%
Reduced
50%
Mainly
Sit/Lie
Mainly in
Bed
Totally Bed
Bound
Totally Bed
Bound
Totally Bed
Bound
Activity & Evidence of
Disease
Normal activity & work
No evidence of disease
Normal activity & work
Some evidence of disease
Normal activity with Effort
Some evidence of disease
Unable Normal Job/Work
Significant disease
Unable hobby/house work
Significant disease
Unable to do any work
Extensive disease
Unable to do most activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
Unable to do any activity
Extensive disease
Death
-
40%
30%
20%
10%
0%
Full
Self-Care
Intake
Full
Normal
Conscious
Level
Full
Full
Normal
Full
Full
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Normal or
reduced
Minimal
to sips
Mouth
care only
Full
Full
Occasional
assistance necessary
Considerable
assistance required
Mainly assistance
Total Care
Total Care
Total Care
-
3
-
Full
Full
or Confusion
Full
or Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Full or Drowsy
+/- Confusion
Drowsy or
Coma +/Confusion
-
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Table 2: Eastern Cooperative Oncology Group (ECOG) Performance Status Scale
Grade
ECOG Performance Status
0
Fully active, able to carry on all pre-disease performance without restriction
1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light
or sedentary nature, e.g., light house work, office work
2
Ambulatory and capable of all self-care but unable to carry out any work activities; up and
about more than 50% of waking hours
3
Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
4
Completely disabled; cannot carry on any self-care; totally confined to bed or chair
5
Dead
4