Diagnostic Specific Criteria
Diagnosis Specific Criteria
E/S Renal Disease_______________________________
1 Creatinine clearance 10 cc/min (< 15 cc/min for diabetics)
2 Serum creatinine > 8.0 mg/dl (> 6.0 mg/dl for diabetics)
3 Urine output < 400 ml within 24 hours
4 Patient or family choose to d/c dialysis
5 Uremia
Cardiac Disease________________________________
1
Recurrent signs or symptoms of CHF
2
Unstable angina requiring opiates or nitrates for pain management
3
Symptoms of CHF or unstable angina present at rest
4
Frequent medication adjustments
5 Class
IV functional status (NYHA): Inability to carry on any
physical activity w/o discomfort
6 Ejection fraction of < 20%
7
Other co-morbid conditions: hx cardiac arrest & resuscitation, hx
syncope, systolic b/p 120 mmHg, cardiogenic brain
embolism.
HIV disease
Pulmonary Disease_____________________________
1 Disabling dyspnea at rest
2 Oxygen dependent
3
Increased ER visits or inpatient hospitialzations for infection or
respiratory failure
4 Decrease in FEVI on serial testing of > 40 ml/yr
5 Presence of Cor Pulmonale or Rt. heart failure
6 Ejection fraction of < 25%
7 Weight loss of 10% over prior 6 months
8 Resting tachycardia > 100/min in patient with COPD
9 Hypoxemia at rest with oxygen
10 PO2 < 55 with oxygen, PCO2 > 50
11 Poor response to bronchodilators
12
O, saturation < 88%
Cancer_______________________________________
1 DX confirmed thru pathology &/or
radiology
2 Evidence of ES disease &/or
metastasis
3 Recent lab or diagnostic
studies to support disease progression
E/S Liver disease________________________________
1 Documentation
of specific liver disease
2 Severely
impaired liver function,
prothrombin time > 5 sec over control
3
Serum albumin < 2.5 gm/dl
4 Jaundice
5 Ascities
6
Edema
7 Hepatic encephalopathy
8 Recurrent variceal bleeding
9 Abnormal liver enzymes
10
Bleeding diathesis and elevated PTT
