LCD/NCD Portal

NCD210.12

 

INTENSIVE BEHAVIORAL THERAPY FOR OBESITY

 

 

Effective Date of this Version

3/6/2012

 

Benefit Category

• Additional Preventive Services.

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

 

Item/Service Description

 

General

• Based upon authority to cover “additional preventive services” for Medicare beneficiaries if certain statutory requirements are met, the Centers for Medicare & Medicaid Services (CMS) initiated a new national coverage analysis on intensive behavioral therapy for obesity.

o Screening for obesity in adults is recommended with a grade of B by the U.S. Preventive Services Task Force (USPSTF) and is appropriate for individuals entitled to benefits under Part A and Part B.

• The Centers for Disease Control (CDC) reported that “obesity rates in the U.S. have increased dramatically over the last 30 years, and obesity is now epidemic in the United States.”

o In the Medicare population over 30% of men and women are obese.

o Obesity is directly or indirectly associated with many chronic diseases including cardiovascular disease, musculoskeletal conditions and diabetes.

 

Indications and Limitations of Coverage

 

Nationally Covered Indications

• Effective for claims with dates of service on or after November 29, 2011, CMS covers intensive behavioral therapy for obesity, defined as a body mass index (BMI) > 30 kg/m2, for the prevention or early detection of illness or disability.

• Intensive behavioral therapy for obesity consists of the following:

o Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed kg/m2).

o Dietary (nutritional) assessment.

o Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

• The intensive behavioral intervention for obesity should be consistent with the 5-A framework that has been highlighted by the USPSTF:

o Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.

o Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.

o Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.

o Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.

o Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

• For Medicare beneficiaries with obesity, who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting, CMS covers:

o One face-to-face visit every week for the first month.

o One face-to-face visit every other week for months 2-6.

o One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg weight loss requirement during the first six months as discussed below.

• At the six month visit, a reassessment of obesity and a determination of the amount of weight loss must be performed.

o To be eligible for additional face-to-face visits occurring once a month for an additional six months, beneficiaries must have achieved a reduction in weight of at least 3kg over the course of the first six months of intensive therapy.

o This determination must be documented in the physician office records for applicable beneficiaries consistent with usual practice.

o For beneficiaries who do not achieve a weight loss of at least 3kg during the first six months of intensive therapy, a reassessment of their readiness to change and BMI is appropriate after an additional six month period.

• For the purposes of this decision memorandum, a primary care setting is defined as one in which there is provision of integrated, accessible health care services by clinicians:

o Who are accountable for addressing a large majority of personal health care needs.

o Developing a sustained partnership with patients.

o Practicing in the context of family and community.

 Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are NOT considered primary care settings under this definition.

• For the purposes of this decision memorandum a “primary care physician” and “primary care practitioner” will be defined consistent with existing sections of the Social Security Act (§1833(u)(6), §1833(x)(2)(A)(i)(I) and §1833(x)(2)(A)(i)(II)).

o §1833(u) (6) Physician Defined.

 For purposes of this paragraph, the term “physician” means a physician described in section 1861(r)(1) and the term “primary care physician” means a physician who is identified in the available data as a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.

o §1833(x)(2)(A) Primary care practitioner—The term “primary care practitioner” means an individual who:

 Is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine.

 Is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in section 1861(aa)(5)).

 

Nationally Non-Covered Indications

• All other indications remain non-covered.

 

Other

• Medicare coinsurance and Part B deductible are waived for this service

• (This NCD last reviewed November 2011)

 

Claims Processing Instructions

• TN 2409 (Medicare Claims Processing) Transmittal Information

 

Coverage Transmittal Link

• http://www.cms.gov/transmittals/downloads/R142NCD.pdf

 

National Coverage Analyses (NCAs)

• This NCD has been or is currently being reviewed under the National Coverage Determination process.

• The following are existing associations with NCAs, from the National Coverage Analyses database.

• Original consideration for Intensive Behavioral Therapy for Obesity (CAG-00423N)

 

 

Medicare NCD Link