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.)
