Hospice Criteria for Congestive Heart Failure (NYHA Class IV)

Heart failure qualifies for Medicare hospice the same way as any illness: a hospice physician, and the attending physician if there is one, must certify a life expectancy of six months or less if the disease runs its normal course. NYHA Class IV is a regional guideline, not a national rule. One example, CGS's Local Coverage Determination (LCD) L34538, looks for Class IV symptoms (discomfort with any activity, sometimes even at rest) in someone already optimally treated, or who is not a candidate for a procedure or has declined one. An ejection fraction of 20% or less can document significant heart failure but is not required.

What are the hospice criteria for congestive heart failure?

Nationally, the person must have Medicare Part A, be certified as above, and choose comfort care instead of treatment to cure. A Medicare Advantage plan does not change the test: once hospice starts, Original Medicare covers care related to the terminal illness, even if your loved one stays in the plan. The specific criteria come from Local Coverage Determinations (LCDs), written by the regional contractors that review hospice claims, so they vary. CGS's LCD L34538, “Hospice Determining Terminal Status,” is one example. It gives two routes to an expected prognosis of six months or less.

Route 1: the heart disease section plus a baseline

• Should be present: optimal treatment. The person is or has been optimally treated for heart disease, or is not a candidate for a surgical procedure, or has declined one.
• Should be present: NYHA Class IV. The person cannot do any physical activity without discomfort, and symptoms of heart failure or angina (chest pain from the heart) may be present even at rest.
• Ejection fraction of 20% or less. This may document significant heart failure, but it is not required if not already available.
• Supporting but not required: treatment-resistant irregular heart rhythms that cause symptoms, a history of cardiac arrest or resuscitation, unexplained fainting, a clot from the heart that reached the brain, or HIV.
• Baseline: a Karnofsky or Palliative Performance Scale score below 70%, plus needing help with two or more of feeding, walking, continence, transfers, bathing and dressing. This alone does not qualify anyone.

Route 2: documented decline, for any diagnosis

This route does not mention NYHA class. It looks for worsening over time, and no set number of signs must be met. Signs relevant to heart failure include more ER visits or hospital stays for the main diagnosis, systolic blood pressure falling below 90, swelling, fluid around the lungs or heart, weakness, rising creatinine, weight loss not explained by something reversible such as diuretics, a falling function score, and needing help with more daily activities.

How firm are these guidelines?

The LCD says “should” means a guideline gets great weight on review but is not obligatory, and that some patients who do not meet the guidelines may still have six months or less if the record documents why. It also says other serious conditions, such as COPD, diabetes and kidney failure, should be considered. Other contractors differ. Wellpoint Federal's LCD L33393 uses nearly the same heart criteria, while Palmetto GBA's cardiopulmonary LCD, L34548, sets no NYHA class or ejection fraction number. It asks hospices to document how the heart disease, complications such as pneumonia or pressure ulcers, and other illnesses combine, and whether most people with those impairments would have a prognosis of six months or less. The hospice applies the LCD used in your area.

What “NYHA Class IV” means

Class IV is the most severe of the four New York Heart Association (NYHA) classes: the person cannot do any physical activity without discomfort, and symptoms may be present even at rest. The NYHA system is a simple way doctors describe how much heart failure limits a person's daily life. The main symptoms are dyspnea (shortness of breath), fatigue, palpitations and chest pain. The class is a clinician's judgment, not a test result, so if the current class is not in the chart, ask the cardiologist to note it.

The four NYHA classes, side by side

Does someone have to be NYHA Class IV to qualify?

No national rule requires it. In L34538, Class IV belongs to Route 1. Someone in Class III could still qualify through documented decline, or through other clinical factors the record explains, if a physician can certify the prognosis. Class IV is not enough by itself either. It describes symptoms, not life expectancy, and L34538 pairs it with optimal treatment and its baseline of low function and help with daily activities.

What ejection fraction qualifies for hospice?

None by itself. Ejection fraction is the percentage of the blood in the heart's lower left chamber that is pumped out with each beat. L34538 and L33393 both say significant heart failure may be documented by a value of 20% or less, and that a value is not required if one is not already available. So no one needs a new echocardiogram just to meet this guideline. A low number does not qualify someone automatically, and a higher one does not rule them out. Both LCDs allow for patients outside the guidelines when the record documents why, which matters for heart failure with preserved ejection fraction (50% or more).

What counts as “optimal treatment”?

L34538 defines optimally treated this way: patients who are not on vasodilators, the medicines that relax blood vessels, have a medical reason for not taking them, such as low blood pressure or kidney disease. Surgery is not required. A person who is not a candidate for a surgical procedure, such as a heart pump or transplant, or who has declined one, meets this guideline.

Is NYHA Class IV the same as Stage D or end-stage heart failure?

They overlap but are not the same. NYHA class rates symptoms and activity. The ACC/AHA stages describe the course of the disease. Stage D means advanced disease with marked symptoms at rest despite maximal medical therapy, according to the staging table reproduced in Wellpoint's LCD, with examples such as people frequently hospitalized for heart failure. L34538's heart criteria use NYHA class, not stage, so being told “Stage D” or “end-stage” does not settle eligibility by itself.

Why the trend matters

Heart failure tends to move in steps: a hospital stay for fluid buildup, a partial recovery, then another crisis a few months later that the body cannot bounce back from as well. Physicians look at this pattern over time: how often hospital stays happen, whether the person recovers to their old baseline, and whether symptoms persist between flare-ups. L34538 says decline should be shown with both a starting point and later findings. A record of dates, weights, hospital visits and changes in what your loved one can do shows the direction that a single appointment may miss.

What hospice actually does for heart failure

The focus shifts to keeping the person comfortable, at home if that is the goal. The team manages breathlessness with positioning, a fan, oxygen if blood oxygen is low, and, when needed, medicines such as morphine, which can ease the feeling of shortness of breath. If that worries you, read does morphine slow breathing.

Nursing and physician services must be available 24 hours a day, 7 days a week, so a frightening night of breathlessness or swelling starts with a call to the hospice. That also matters for cost: Medicare.gov warns that ER visits, hospital stays and ambulance rides are not covered on hospice unless the hospice team arranges them or they are unrelated to the terminal illness. See can you go to the ER or be hospitalized on hospice. For the day-to-day picture of living on hospice with heart failure, see hospice care for congestive heart failure.

What to bring to the evaluation

Because the physician is judging the direction of the illness, a short written record from the family helps. Gather what you can, with dates and numbers wherever possible:

• Hospitalizations and ER visits for fluid overload or worsening heart failure in the past several months, and whether each ended back at the old baseline or a lower one.
• Daily weights or swelling trends, if you track them, which show fluid that medication is struggling to control.
• What changed in daily function, such as walking, dressing and bathing, over the last three to six months.
• Symptoms at rest now versus before: breathlessness, fatigue, chest discomfort while simply sitting.
• The current medication list, plus why any heart medicine was stopped and which procedures were offered or declined.
• Any echocardiogram report that already exists.

These notes do not diagnose anything. They show the physician the trend rather than a single good or bad day.

A common misconception

Many families assume a low ejection fraction automatically qualifies, or that a person must stop all heart medications first. Neither is true. Eligibility is a clinical determination made by physicians, not a checklist the family scores, and this guide is not medical advice. This page tells you what to ask for, not whether your loved one qualifies.

Frequently asked questions

Will hospice stop the heart-failure medications?

Not automatically. Hospice covers drugs for symptom control related to the terminal illness, so medications that relieve symptoms, such as diuretics for fluid, can continue. The team reviews the regimen and may stop what no longer helps. For elections on or after October 1, 2026, anything the hospice decides is unrelated and will not cover must be listed on a written addendum within the first 5 days, and updated within 3 days if a plan change affects it.

What if my loved one improves after starting hospice?

Heart failure is reassessed at each benefit period: two 90-day periods, then unlimited 60-day periods. Under L34538, someone who stabilizes or improves but can reasonably be expected to keep declining remains eligible. If a hospice physician can no longer certify the prognosis, the hospice may discharge them. Regular Medicare then resumes, and they can elect hospice again if they become eligible. Your loved one can also stop hospice at any time. Hospice is not a one-way door.

Do we need the cardiologist's permission to ask about hospice?

No. You can ask the cardiologist or primary doctor for a referral, or contact a hospice directly. If the cardiologist is the attending physician named on the election statement, they certify too. Your loved one chooses who is named and can change that choice with a signed statement (42 CFR 418.24). If there is no attending physician, the hospice physician's certification is enough.

Can someone with an ICD or pacemaker go on hospice?

Yes. Neither device has to be turned off to enroll, and turning off an ICD's shocks is a choice. See should you turn off a pacemaker or defibrillator on hospice. Enrolling in hospice is also not a DNR, and a DNR is not required.

What to do next

If your loved one is short of breath at rest, tiring with the smallest activity, and returning to the hospital despite good treatment, the right step is to request a hospice evaluation. Ask the cardiologist or primary doctor for a referral, or contact a hospice directly, and ask whether there is any charge. The hospice's medical director or physician, not the family, decides eligibility. Medicare's hospice booklet also says that before starting hospice you can get a one-time consultation with a hospice medical director or hospice doctor about care options and managing pain and symptoms, even if you decide against hospice. If an evaluation does not lead to admission now and the decline continues, you can ask again later.

When you're ready to compare Medicare-certified hospices near you, you can search our directory by city. You may also find it helpful to read when heart failure qualifies for hospice, how to qualify for hospice with CHF, and how Medicare covers hospice care.