**

A. Inpatient Hospital Stay for Alcohol Detoxification

**

Many hospitals provide detoxification services during the more acute stages of
alcoholism or alcohol withdrawal. When the high probability or occurrence of
medical complications (e.g., delirium, confusion, trauma, or unconsciousness)
during detoxification for acute alcoholism or alcohol withdrawal necessitates
the constant availability of physicians and/or complex medical equipment found
only in the hospital setting, inpatient hospital care during this period is
considered reasonable and necessary and is therefore covered under the
program. Generally, detoxification can be accomplished within two to three
days with an occasional need for up to five days where the patients condition
dictates. This limit (five days) may be extended in an individual case where
there is a need for a longer period for detoxification for a particular
patient.

In such cases, however, there should be documentation by a physician which
substantiates that a longer period of detoxification was reasonable and
necessary. When the detoxification needs of an individual no longer require an
inpatient hospital setting, coverage should be denied on the basis that
inpatient hospital care is not reasonable and necessary as required by
1862(a)(l) of the Social Security Act (the Act). Following detoxification a
patient may be transferred to an inpatient rehabilitation unit or discharged
to a residential treatment program or outpatient treatment setting.

**

B. Inpatient Hospital Stay for Alcohol Rehabilitation

**

Hospitals may also provide structured inpatient alcohol rehabilitation
programs to the chronic alcoholic. These programs are composed primarily of
coordinated educational and psychotherapeutic services provided on a group
basis. Depending on the subject matter, a series of lectures, discussions,
films, and group therapy sessions are led by either physicians, psychologists,
or alcoholism counselors from the hospital or various outside organizations.
In addition, individual psychotherapy and family counseling (see 70.1) may be
provided in selected cases. These programs are conducted under the supervision
and direction of a physician. Patients may directly enter an inpatient
hospital rehabilitation program after having undergone detoxification in the
same hospital or in another hospital or may enter an inpatient hospital
rehabilitation program without prior hospitalization for detoxification.

Alcohol rehabilitation can be provided in a variety of settings other than the
hospital setting. In order for an inpatient hospital stay for alcohol
rehabilitation to be covered under Medicare it must be medically necessary for
the care to be provided in the inpatient hospital setting rather than in a
less costly facility or on an outpatient basis. Inpatient hospital care for
receipt of an alcohol rehabilitation program would generally be medically
necessary where either (l) there is documentation by the physician that recent
alcohol rehabilitation services in a less intensive setting or on an
outpatient basis have proven unsuccessful and, as a consequence, the patient
requires the supervision and intensity of services which can only be found in
the controlled environment of the hospital, or (2) only the hospital
environment can assure the medical management or control of the patients
concomitant conditions during the course of alcohol rehabilitation. (However,
a patients concomitant condition may make the use of certain alcohol
treatment modalities medically inappropriate.)

In addition, the active treatment criteria (see the [Medicare Benefit Policy
Manual](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673), Chapter
2, Inpatient Psychiatric Hospital Services, 20) should be applied to
psychiatric care in the general hospital as well as to psychiatric care in a
psychiatric hospital. Since alcoholism is classifiable as a psychiatric
condition the active treatment criteria must also be met in order for
alcohol rehabilitation services to be covered under Medicare. (Thus, it is the
combined need for active treatment and for covered care which can only be
provided in the inpatient hospital setting, rather than the fact that
rehabilitation immediately follows a period of detoxification which provides
the basis for coverage of inpatient hospital alcohol rehabilitation programs.)

Generally 16-19 days of rehabilitation services are sufficient to bring a
patient to a point where care could be continued in other than an inpatient
hospital setting. An inpatient hospital stay for alcohol rehabilitation may be
extended beyond this limit in an individual case where a longer period of
alcohol rehabilitation is medically necessary. In such cases, however, there
should be documentation by a physician which substantiates the need for such
care. Where the rehabilitation needs of an individual no longer require an
inpatient hospital setting, coverage should be denied on the basis that
inpatient hospital care is not reasonable and necessary as required by 1862
(a)(l) of the Act.

Subsequent admissions to the inpatient hospital setting for alcohol
rehabilitation follow-up, reinforcement, or recap treatments are considered
to be readmissions (rather than an extension of the original stay) and must
meet the requirements of this section for coverage under Medicare. Prior
admissions to the inpatient hospital setting - either in the same hospital or
in a different hospital - may be an indication that the active treatment
requirements are not met (i.e., there is no reasonable expectation of
improvement) and the stay should not be covered. Accordingly, there should be
documentation to establish that readmission to the hospital setting for
alcohol rehabilitation services can reasonably be expected to result in
improvement of the patients condition. For example, the documentation should
indicate what changes in the patients medical condition, social or emotional
status, or treatment plan make improvement likely, or why the patients
initial hospital treatment was not sufficient.

**

C. Combined Alcohol Detoxification/Rehabilitation Programs

**

Medicare Administrative Contractors (MACs) should apply the guidelines in A.
and B. above to both phases of a combined inpatient hospital alcohol
detoxification/rehabilitation program. Not all patients who require the
inpatient hospital setting for detoxification also need the inpatient hospital
setting for rehabilitation. (See [130.1](https://www.cms.gov/medicare-
coverage-database/details/ncd-
details.aspx?NCDId=26&ncdver=1&DocID=130.1&kq=true&SearchType=Advanced&bc=EAAAAAgAAAAA&)
for coverage of outpatient hospital alcohol rehabilitation services.) Where
the inpatient hospital setting is medically necessary for both alcohol
detoxification and rehabilitation, generally a 3-week period is reasonable and
necessary to bring the patient to the point where care can be continued in
other than an inpatient hospital setting.

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/MACs based on accepted medical practice with the advice of their medical
consultant. (In hospitals under PSRO review, PSRO determinations of medical
necessity of services and appropriateness of the level of care at which
services are provided are binding on A/MACs for purposes of adjudicating
claims for payment.)