Terminal Illness - Deference to Physician Determination

A case now being briefed to the U.S. Court of Appeals for the Sixth Circuit raises critical issues about how terminal illness is determined for hospice eligibility. (In Home Health v. Kennedy, No. 25-3542).

An ALJ rejected over 100 claims by a Toledo, Ohio hospice. But the hospice and its professional society amici argue that the ALJ lacked sufficient basis to reject their claims and deny payment. The case focuses on the appropriate standard of review.

The hospice and professional societies argue that there is significant "imprecision of terminal illness prognostication." Therefore, ALJs must defer to physician determinations unless they have "clear and objective evidence" that the determination is inaccurate. 

Not only is this approach consistent with Medicare law but it is also good policy. If ALJs can too easily deny claims, physicians will be chilled and deterred from qualifying patients for hospice.