1 must be met and either 2 or 3 must be met.

1. Rapid Disease Progression (all in this section must be met)
(Rapid progression of ALS as demonstrated by all of the following characteristics occurring within the 12 months preceding initial certification)

a. Progression from independent ambulation to wheelchair to bed-bound status?
b. Progression from normal to barely intelligible or unintelligible words?
c. Progression from normal to pureed diet?
d. Progression from independence in most or all activities of daily living (ADLs) to needing major caregiver assistance in all ADLs?

AND

2. Critical Nutritional Impairment (all in the section must be met)
(Nutritional impairment as demonstrated by all of the following characteristics occurring within the 12 months preceding initial certification)

a. Is oral intake of nutrients and fluids insufficient to sustain life?
b. Is patient continuing to loose weight?
c. Are there signs of dehydration or hypovolemia?
d. Is absence of artificial feeding sufficient to sustain life, but is not relieving hunger?

OR

3. Life-threatening complication (all in this section must be met)
(Complications as demonstrated by all of the following characteristics occurring within the 12 months preceding initial certification)

a. Has there been recurrent aspiration pneumonia, with or without tube feedings?
b. Any upper urinary tract infection? (e.g. pyelonephritis)
c. Any Hx of sepsis in the past 12 months?
d. Any recurrent fever after antibiotic therapy?
e. Hx or presence of stage 3 or 4 decubitis ulcers?