As of January 1, 2018, the Alliance began authorizing palliative care services to its Medi-Cal members, when those services are medically necessary. The goal of palliative care is to relieve or mitigate the burden/symptoms of suffering in members with life threatening illness. It may include the services of a visiting nurse, social worker, chaplain or other adjunctive therapies in the member’s home. The provision of palliative care does not result in the elimination or reduction of any covered benefits or services. Members can receiving palliative care services and home health services. Palliative care services may be authorized while the member is also receiving curative care and until the condition improves, stabilizes, or results in death.

Disease Specific Eligibility Criteria

Alliance Medi-Cal members are eligible for palliative care services if they have any of the following conditions:

• Congestive heart failure (CHF) (must meet both of the following):
  • New York Heart Association (NYHA) class 3 or higher or at least one (1) hospitalization for heart failure in six (6) months with no further invasive interventions planned; and
  • Ejection fraction <30% for systolic failure or significant comorbidities.
• Chronic obstructive pulmonary disease (COPD) (must meet either of the following):
  • Forced Expiratory Volume (FEV) 1 less than 35% and 24 hour oxygen requirement of less than 3 L; or
  • 24 hour oxygen requirement of greater than or equal to 3 L per minute.
• Advanced cancer (must meet both of the following):
  • Stage 3 or 4 solid organ cancer, lymphoma, or leukemia; and
  • A Karnofsky Performance Scale (KPS) score less than or equal to 70 or has failure of two (2) lines of standard of care therapy (chemotherapy or radiation therapy).
• Liver disease (must meet either of the following):
  • Evidence of irreversible liver damage, serum albumin < 3 and INR > 1.3 and ascites, subacute bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, or recurrent esophageal varices; or
  • Model of End Stage Liver Disease (MELD) score of greater than 19.
• Advanced Dementia/Alzheimer’s Dementia (needs to meet 4 out 5 criteria):
  • Profound memory deficits
  • Functional impairment (ADL dependencies)
  • Minimal communication
  • Decreased oral intake and/or significant weight loss in last 6 months
  • Malnutrition

Authorization

To submit a request, please submit the Palliative Care Prior Authorization Form. Referral and care coordination for palliative services will be provided to the member within the standard timely access requirements.