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 A/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/MACs for purposes of adjudicating claims for payment.)
