CMS Pub. 100-03, ch. 1, § 130.2

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 Manual, 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 patient’s 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 patient’s condition. (See also §70.1.) The frequency of treatment and period of time over

which it occurs must also be reasonable and necessary.