LCD/NCD Portal

NCD130.2

 

OUTPATIENT HOSPITAL SERVICES FOR TREATMENT OF ALCOHOLISM

 

Effective Date of this Version

• This is a longstanding national coverage determination.

• The effective date of this version has not been posted.

 

Benefit Category

• Outpatient Hospital Services Incident to a Physician's Service.

• Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

 

Item/Service Description

• 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.

 

Indications and Limitations of Coverage

• 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.

o 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, §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 patient's condition (see the Medicare Benefit Policy Manual, Chapter 16 §20).

o Thus, educational services and family counseling would only be covered where they are directly related to treatment of the patient's condition. The frequency of treatment and period of time over which it occurs must also be reasonable and necessary.

 

Cross Reference

See the NCD Manual §70.1.

 

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