Appeal type: unknown
Decision: unknown

 The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.  The rules state that The Centers for Medicare & Medicaid Services recognizes that there are similarities between the approach to treatment of drug abuse and alcohol detoxification and rehabilitation. However, the intensity and duration of treatment for drug abuse may vary (depending on the particular substance(s) of abuse, duration of use, and the patient's medical and emotional condition) from the duration of treatment or intensity needed to treat alcoholism.  Indications and Limitations of Coverage Accordingly, when it is medically necessary for a patient to receive detoxification and/or rehabilitation for drug substance abuse as a hospital inpatient, coverage for care in that setting is available. Coverage is also available for treatment services that are provided in the outpatient department of a hospital to patients who, for example, have been discharged from an inpatient stay for the treatment of drug substance abuse or who require treatment but do not require the availability and intensity of services found only in the inpatient hospital setting. The coverage available for these services is subject to the same rules generally applicable to the coverage of outpatient hospital services. (See the Medicare Benefit Policy Manual (BPM), Chapter 6, "Hospital Services Covered Under Part B," 20.) The services must also be reasonable and necessary for treatment of the individual's condition. (See the Medicare BPM, Chapter 16, "General Exclusions from Coverage," 90.) Decisions regarding reasonableness and necessity of treatment, the need for an inpatient hospital level of care and length of treatment, should be `made by A/B Medicare Administrative Contractors (MACs) based on accepted medical practice with the advice of their medical consultant. (In hospitals under Quality Improvement Organization (QIO) review, QIO determinations of medical necessity of services and appropriateness of the level of care at which services are provided are binding on A/B MACs for purposes of adjudicating claims for payment.) You can find this rule at National Coverage Determination (NCD) for Treatment of Drug Abuse (Chemical Dependency) (130.6).  The rules state withdrawal is an accepted treatment for narcotic addiction, and Part B payment can be made for these services if they are provided by the physician directly or under his personal supervision and if they are reasonable and necessary. In reviewing claims, reasonableness and necessity are determined with the aid of the B/Medicare Administrative Contractor's medical staff. Drugs that the physician provides in connection with this treatment are also covered if they cannot be self-administered and meet all other statutory requirements. You can find this rule at National Coverage Determination (NCD) for Withdrawal Treatments for Narcotic Addictions (130.7).   If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.  The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract also says that the Plan covers mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it. You can find this information on page 89 of the Plan's 2021Evidence of Coverage.