Does hospice pay for luprone injections

ErinS, BSN, RN · Feb 23, 2011

If it is related to terminal illness hospice is responsible for it, meaning if the pt is on hospice and has this done, his insurance/medicare will not pay for it. However, the hospice medical director and hospice manager can make a decision to not cover a medication. So if the pt wanted injections, hospice will need to cover them or he needs to go off hospice. What I would do is focus on managing his symptoms over the next 3 months with the understanding that if the symptoms are managed, he may not need the lupron. But if he still wants it, he will have to go off hospice. A lot can happen in 3 months and it may be a moot point by then.

SoCalRN1970 · Feb 23, 2011

We are start up hospice. We just admitted new patient with diagnosis of CA of prostate metastatic disease to spine, bones, lungs. His oncologist and primary MD want to give him Luprone injections to suppress the tumor (as palliative measure) every 3 months. Does the hospice need to pay for Luprone? (each injection cost about $3,000). We do not know what to do, and can`t find answer from anyone.

This is a hospice specific issues. They have the ability to pay or NOT to pay for this. It's also important to the hospice to know that denying payment on such an expensive drug may severe any future referral to the hospice.

I have worked at many hospices. Choice to pay or not to pay for something of this nature is up to the hospice itself. I have had patients who go weekly or monthly to the hospital for thorecentesis for palliative treatment I have had other hospice agencies deny patients this treatment because of the all mighty $$. There is no right answer, but rather this type of coverage is entirely up to the individual hospice. ONe could argue that blood transfusions are palliative for those who suffer from leukemia, or chronic anemia related to disease process. Will hospices pay? yes, some do, some don't . It depends unfortunately how tight the purse strings are. There is no magic place for the answer other than the administrator who is governing the finances in your office. The cost of this medication is astronomical. If the family or patient can pay privately this is not an issue, but often this is not the case. Giving that medicare pays only 150ish a day for care, the monthly costs of other medicaitons, care and staff... the odds are.. Your hospice will not pay for this medication unless your agency is concerned about future referrals from this MD if this treatment is denied.

Sorry sad but true. The dollar runs this business.

tewdles, RN · Feb 24, 2011

If the medication is intended for palliative relief of symptoms for the primary hospice diagnosis it should be the financial responsibility of the hospice provider. Suppression of tumor growth may or may not be palliative...this med is most commonly used (in my experience) to suppress tumor growth and prolong life. What symptom are they hoping to relieve with these injections? In what way will the medication improve the quality of life?

If the hospice provider does not agree with this medical treatment plan they need to discuss the plan with the primary physician who is managing the hospice medical care. If the primary MDs are making unrealistic and expensive recommendations or choices about medications the hospice medical director should be intervening directly with that physician.

What the oncologist may want is typically not relevant to the hospice plan of care, they are generally engaged in the aggressive and curative treatment of the disease. Nothing against oncologists...they just don't practice hospice and many of them actually don't refer to hospice.

So, bottom line...if it is ordered and included in your hospice POC (for the primary hospice dx) your agency MUST pay for it.