What Is a Local Coverage Determination for Hospice?

A Local Coverage Determination for hospice is a regional Medicare policy, issued by the Medicare Administrative Contractor (MAC) that processes claims in a given area, setting out the clinical evidence a hospice must document before Medicare will pay for care. LCDs sit underneath the national hospice framework and fill in its clinical specifics: what counts as adequate proof that a patient has a life expectancy of six months or less. Because each MAC writes its own, the exact benchmarks can differ from one region to another, and those regional differences effectively decide whether a hospice claim is approved or denied.

Which LCD Applies to a Given Hospice

The LCD that governs a patient’s care is the one published by the MAC assigned to the hospice provider’s location, not the patient’s. MACs are private companies that CMS contracts with to process Medicare claims and develop local coverage rules for their jurisdictions.¹

The most reliable place to look up the applicable policy is the CMS Medicare Coverage Database, which allows searches by state or keyword. MACs also post their LCDs on their own contractor websites, which can be a faster route once you know which MAC covers your area.²

The LCD and Its Companion Article

The LCD itself contains the clinical coverage policy. Billing codes and technical documentation requirements sit in a separate Local Coverage Article that accompanies the LCD.¹ Both are needed to submit claims correctly. Checking only the LCD, without pulling the companion Article, is a common source of avoidable denials.

Why LCDs Aren’t Identical Across the Country

CMS sets the national framework for hospice coverage. Within that framework, each MAC has discretion to establish clinical specifics — one MAC may require more granular documentation for a given diagnosis, or use slightly different functional benchmarks, than another. A hospice operating in multiple states may need to follow different LCD requirements depending on which MAC processes claims for each location. Assuming national standards are enough is where claim denials most often start.

What the LCD Requires Clinically

An LCD requires clinical evidence that supports the physician’s terminal prognosis. Documentation falls into two tracks: disease-specific criteria and non-disease-specific indicators of decline.³ A patient does not need to meet every criterion in every category, but the record must paint a coherent clinical picture that supports a life expectancy of six months or less.

Disease-Specific Criteria

LCDs provide detailed guidelines for common terminal diagnoses, including cancer, heart disease, pulmonary disease, dementia, liver disease, renal failure, stroke, and HIV/AIDS.¹ Each category has its own benchmarks.

A patient with advanced heart failure would typically need to demonstrate New York Heart Association Class IV status, meaning symptoms are present even at rest. Significant heart failure may also be documented by an ejection fraction of 20% or less, though the LCD does not require that measurement if it hasn’t already been obtained.³

For pulmonary disease, LCDs look for severe chronic lung disease with disabling shortness of breath at rest that responds poorly to treatment and has left the patient largely confined to a bed or chair. Spirometry showing an FEV1 below 30% of predicted after bronchodilator use provides objective support, but testing is not required if unavailable.³

Dementia and the FAST Scale

Dementia eligibility uses a different framework. LCDs rely on the Functional Assessment Staging (FAST) scale, a seven-stage tool designed for Alzheimer’s disease. A patient generally needs to reach FAST Stage 7C or beyond. At that point the person has lost the ability to walk independently, has minimal meaningful speech (roughly five words or fewer per day), and is incontinent.

Reaching Stage 7C alone is not enough. The LCD also requires at least one comorbidity (such as heart failure, COPD, cancer, or kidney or liver disease) or a dementia-related secondary condition like recurrent infections, advanced pressure ulcers, persistent fever, or significant weight loss.¹ Because the FAST scale was designed for Alzheimer’s specifically, non-Alzheimer’s dementias do not always follow the same progression, and providers documenting eligibility for those conditions often need to lean more on non-disease-specific decline criteria.

Non-Disease-Specific Indicators of Decline

Regardless of diagnosis, the record must show a pattern of overall decline. LCDs accept several kinds of evidence:³

Functional deterioration measured by the Karnofsky Performance Status or Palliative Performance Scale, with a score below 70% due to disease progression as a key threshold.¹
Unintentional weight loss of more than 10% of body weight over the preceding six months, not explained by reversible causes such as depression or diuretic use.
Increasing dependence, with the patient needing help in two or more activities of daily living such as walking, dressing, bathing, eating, or managing continence.
Worsening lab results or symptoms that reflect irreversible disease progression.

The clinical narrative tying these findings together matters as much as the findings themselves. It must show that the patient’s condition is worsening despite treatment, or that the patient has chosen to stop pursuing treatment aimed at controlling the disease. A chart full of objective data points without a narrative connecting them to a six-month prognosis is one of the most common reasons hospice claims run into trouble.³

How LCDs Apply at Each Recertification

The Medicare hospice benefit is structured as a series of election periods: two 90-day periods followed by an unlimited number of 60-day periods for as long as the patient continues to qualify.⁴ At the start of each new period, the hospice medical director must recertify that the patient remains terminally ill, and the LCD criteria come back into play every time.⁵

Face-to-Face Encounters

Starting with the third benefit period (the first 60-day period), a hospice physician or a nurse practitioner employed by the hospice must meet with the patient in person before recertification. This face-to-face encounter must happen no more than 30 calendar days before the start of that benefit period, and the requirement applies to every subsequent recertification.⁶

A nurse practitioner can conduct the visit, but only the certifying physician can sign the recertification and the physician narrative. When a nurse practitioner performs the encounter, the documentation must confirm that the clinical findings were communicated to the certifying physician for use in the eligibility determination.⁷ The attestation can be a separate section of the recertification form, an addendum, or a signed clinical note in the medical record that includes the date of the visit and the practitioner’s signature.

The Recertification Narrative

Each recertification must include a written narrative from the certifying physician explaining, in clinical terms, why the patient still has a life expectancy of six months or less. The narrative should reference specific findings — recent changes in functional status, new complications, weight trends, lab results — and connect those findings to the terminal prognosis. When a face-to-face encounter has been conducted, the narrative must incorporate the findings from that visit.⁴ A generic narrative that could apply to any patient with the same diagnosis is the kind of documentation that draws scrutiny.

When an LCD-Based Denial Happens

Most hospice coverage disputes come down to whether the clinical documentation adequately supports a six-month prognosis under the applicable LCD. When a MAC denies a claim on that ground, the patient has appeal rights, beginning with a redetermination by the MAC that made the initial decision. The patient files by following the instructions on the Medicare Summary Notice, and a decision generally comes within 60 days.⁸ Further levels — reconsideration by a Qualified Independent Contractor, an Administrative Law Judge hearing, Medicare Appeals Council review, and federal district court — are available if earlier levels are unfavorable.⁹

A separate track applies when a hospice decides to end services because it has determined the patient is no longer terminally ill. The patient must receive a Notice of Medicare Non-Coverage at least two days before covered services end, and the notice explains how to request an expedited review from the Beneficiary and Family Centered Care Quality Improvement Organization. The request must be made no later than noon the day before the listed termination date.¹⁰

On appeal, the most productive moves target the specific LCD criteria the MAC found lacking: strengthening the physician narrative, adding updated functional assessments, and providing recent clinical data. Where a denial reflects missing LCD-required documentation rather than a genuine disagreement about the patient’s condition, the fix is usually a matter of assembling the evidence that already exists and submitting it at the redetermination stage.

1
Centers for Medicare & Medicaid Services. LCD – Hospice Determining Terminal Status (L34538)
2
CGS Medicare. Hospice Quick Resource Tools
3
Centers for Medicare & Medicaid Services. LCD – Hospice Determining Terminal Status (L33393)
4
Medicare. Hospice Care Coverage
5
Medicare. Medicare and Hospice Benefits – Getting Started
6
eCFR. 42 CFR 418.22 – Certification of Terminal Illness
7
Centers for Medicare & Medicaid Services. Face-to-Face Requirement Affecting Hospice Recertification
8
Medicare. Appeals in Original Medicare
9
Centers for Medicare & Medicaid Services. Original Medicare (Fee-for-Service) Appeals
10
Medicare. Fast Appeals