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NCD130.3

 

CHEMICAL AVERSION THERAPY 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

• 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.

 

Indications and Limitations of Coverage

• Available evidence indicates that chemical aversion therapy may be an effective component of certain alcoholism treatment programs, particularly as part of multimodality treatment programs which include other behavioral techniques and therapies, such as psychotherapy.

o Based on this evidence, CMS's medical consultants have recommended that chemical aversion therapy be covered under Medicare.

o 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.

o 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 multimodality treatment programs.)

o Follow-up treatments for chemical aversion therapy can generally be provided on an outpatient basis.

o 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 intermediaries based on accepted medical practice with the advice of their medical consultant. (In hospitals under 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 title XVIII fiscal intermediaries for purposes of adjudicating claims for payment.)

 

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