Heart Disease

The patient has 1 and either 2 or 3

  1. CHF with NYH class IV symptoms and both

    a. Significant symptoms at rest

    b. Inability to carry out even minimal physical activity without difficulty breathing or chest pain

  2. Patient is optimally treated (example: diuretics, vasodilators, ACEI, or hydralazine and nitrates)

  3. Chest pain at rest, resistant to standard nitrate therapy, and is either not a candidate for / or has declined invasive procedures

    Supporting Documentation Includes:

    • Ejection Fraction is less than or equal to 20%

    • Treatment resistant dysrythmias

    • History of cardiac related syncope

    • Cardiovascular Accident due to a cardiac embolism

    • History of Cardiac Resuscitation

    • Concomitant HIV disease

Liver Disease

The patient has both 1 and 2

  1. End stage liver disease as demonstrated by A or B, & C

    A. PT > 5 sec OR B. INR > 1.5


    C. Serum albumin < 2.5 gm / dl

  2. One or more of the following conditions:

    • Refractory Ascites

    • History of spontaneous bacterial peritonities

    • Hepatorenal syndrome

    • Refractory hepatic encephalopathy

    • History of recurrent variceal bleeding

    Supporting Documentation Includes:

    • Progressive malnutrition

    • Muscle wasting with decreased strength

    • Ongoing alcoholism (>80 gm ethanol / day)

    • Hepatocellular CA HBsAg positive

    • Hep. C refractory to treatment

Pulmonary disease

Severe chronic lung disease as documented by 1, 2 and 3

  1. The patient has all of the following:

    • Disabling dyspnea at rest

    • Little of no response to bronchodilators

    • Decreased functional capacity


  2. Progression of disease as evidenced by a recent history of increasing office, home or ED visits and / or hospitalizations for pulmonary infection and / or respiratory failure.


  3. Documentation within the past 3 months of:

    • Hypoxemia at rest on room air (P02 < 55 mmHg by ABG)

    • OR

    • Oxygen saturation < 88%

    • OR

    • Hypercapnia evidenced by pC02 > 50 mmHg

    Supporting Documentation:

    • Cor pulmonal and right heart failure

    • Unintentional and progressive weight loss