(Medicare National Coverage Determinations Manual)

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 counsel ing (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, 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 h ospital.  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 expectat ion 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 patie nts 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  A/B 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 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 the A/B MAC (A) 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 the A/B MAC (A) for purposes of adjudicating claims for payment.)  130.2 - Outpatient Hospital Services for Treatment of Alcoholism  (Rev. 1, 10-03-03) CIM 35 -22  Some hospitals also provide services on an outpatient basis, either individually or as part of a day hospitalization program, for treatment of alcoholism.  These services may include, for example, drug therapy, psychotherapy, and patient education and may be furnished by physicians, psychologists, nurses, and alcoholism counselors to individuals who have been discharged from an inpatient hospital stay for treatment  of alcoholism and require continued treatment or to individuals from the community who require treatment but do not require the inpatient hospital setting.   Coverage is available for both diagnostic and therapeutic services furnished for the treatment of alcoholism by the hospital to outpatients subject to the same rules applicable to outpatient hospital services in general (see the Medicare Benefit Policy Man ual, Chapter 6, Hospital Services Covered Under Part B, 20).  While there is no coverage for day hospitalization programs, per se, individual services which meet the requirements in the Medicare Benefit Policy Manual, Chapter 6, Hospital Services Covered Under Part B, 20 may be covered.  (Meals, transportation, and recreational and social activities do not fall within the scope of covered outpatient hospital services under Medicare.)  All services must be reasonable and necessary for diagnosis or treatment of the patients condition (see the Medicare Benefit Policy Manual, Chapter 16, General Exclusions from Coverage, 20).  Thus, educational services and family counseling would only be covered where they are directly related to treatment of the patients condition.  (See also 70.1.) The frequency of treatment and period of time over which it occurs must also be reasonable and necessary.   130.3 - Chemical Aversion Therapy for Treatment of Alcoholism  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)  Chemical aversion therapy is a behavior modification technique that is used in the treatment of alcoholism.  Chemical aversion therapy facilitates alcohol abstinence through the development of conditioned aversions to the taste, smell, and sight of alcohol beverages.  This is accomplished by repeatedly pairing alcohol with unpleasant symptoms (e.g., nausea) which have been induced by one of several chemical agents.  While a number of drugs have been employed in chemical aversion therapy, the three most commonly used are emetine, apomorphine, and lithium.  None of the drugs being used, however, have yet been approved by the Food and Drug Administration specifically for use in chemical aversion therapy for alcoholism.  Accordingly, when these drugs are being employed in conjunction with this therapy, patients undergoing this treatment need to be kept under medical observation.  Available evidence indicates that chemical aversion therapy may be an effective component of certain alcoholism treatment programs, particularly as part of multi-modality treatment programs which include other behavioral techniques and therapies, such as psychotherapy.  Based on this evidence, the Centers for Medicare & Medicaid Services medical consultants have recommended that chemical aversion therapy be covered under Medicare.  However, since chemical aversion therapy is a demanding therapy which may not be appropriate for all Medicare beneficiaries needing treatment for alcoholism, a physician should certify to the appropriateness of chemical aversion therapy in the individual case.  Therefore, if chemical aversion therapy for treatment of alcoholism is determined to be reasonable and necessary for an individual patient, it is covered under Medicare.   When it is medically necessary for a patient to receive chemical aversion therapy as a hospital inpatient, coverage for care in that setting is available.  (See 130.1 regarding coverage of multi- modality treatment programs.)  Follow-up treatments for chemical aversion therapy can generally be provided on an outpatient basis.  Thus, where a patient is admitted as an inpatient for receipt of chemical aversion therapy, there must be documentation by the physician of the need in the individual case for the inpatient hospital admission.  Decisions regarding reasonableness and necessity of treatment and the need for an inpatient hospital level of care should be made by the A/B MAC (A) based on accepted medical practice with the advice of their medical consultant.  (In hospitals under Qualit y 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 the A/B MAC (A) for purposes of adjudicating claims for payment.)  130.4 - Electrical Aversion Therapy for Treatment of Alcoholism  (Rev. 1, 10-03-03) CIM 35 -23.1  Electroversion  Therapy, Electro -shock Therapy, Noxious Faradic Stimulation.  Electrical aversion therapy is a behavior modification technique to foster abstinence from ingestion of alcoholic beverages by developing in a patient conditioned aversions to their taste, smell and sight through electric stimulation.  Electrical aversion therapy has not been shown to be safe and effective and therefore is excluded from coverage.  (See also 130.1, 130.3 , and 30.1).  130.5 - Treatment of Alcoholism and Drug Abuse in a Freestanding Clinic  (Rev. 1, 10-03-03) CIM 35 -22.3  Coverage is available for alcoholism or drug abuse treatment services (such as drug therapy, psychotherapy, and patient education) that are provided incident to a physicians professional service in a freestanding clinic to patients who, for example, have been discharged from an inpatient hospital stay for the treatment of alcoholism or drug abuse or to individuals who are not in the acute stages of alcoholism or drug abuse but require treatment.  The coverage available for these services is subject to the same rules generally applicable to the coverage of clinic services.  (See the Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, 60.1; the Medicare Claims Processing Manual, Chapter 12, Physician/Practitioners Billing , 10; the Medicare General Information, Eligibility, and Entitlement Manual, Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30. Of course, the services also must be reasonable and necessary for the diagnosis or treatment of the individuals alcoholism or drug abuse.  The Part B psychiatric limitation (see the Medicare General Information, Eligibility, and Entitlement Manual,  Chapter 3, Deductibles, Coinsurance Amounts, and Payment Limitations, 30) would apply to alcoholism or drug abuse treatment services furnished by physicians to individuals who are not hospital inpatients.   130.6 - Treatment of Drug Abuse (Chemical Dependency)  (Rev. 173, Issued: 09-04- 14, Effective: Upon Implementation: of ICD -10, Implementation: Upon Implementation of ICD -10)