Medicare Guidelines for Non-Cancer

LIVER DISEASE (Both 1 & 2 and at least 1 of 3 must be present)

 

1&2 and

e1 of 3 must be present)

End-Stage Liver Disease must have at least one of the following:

 

·        Prolonged prothrombin time > 5 sec. over control orINR 1.5

·        Low serum albumin <2.5 gm/dl

·        Ascities

o   Spontaneous bacterial peritonitis

o   Hepatorenal syndrome

o   Recurrent Variceal Bleeding

o   Hepatc Encephalopathy

 

            ICD-9 Codes that support medical necessity:

 

o   155.0 Liver Cancer

o   571.2 Alcoholic Cirrhosis of liver

o   571.40-571.49 Chronic hepatitis

o   571.5 Cirrhosis of liver w/o mention of alcohol

o   571.6 Biliary Cirrhosis

o   572.2 Hepatic coma

o   572.4 Hepatorenal syndrome

 

“Local Coverage Determination Policies 2004”**