LCD/NCD Portal

NCD40.5

 

TREATMENT OF OBESITY

 

Effective Date of this Version

5/30/2006

 

Benefit Category

• Incident to a physician's professional Service.

• Physicians' Services.

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

 

Item/Service Description

A. General

• Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, and hypothalamic lesions, or can aggravate a number of cardiac and respiratory diseases as well as diabetes and hypertension.

o Non-surgical services in connection with the treatment of obesity are covered when such services are an integral and necessary part of a course of treatment for one of these medical conditions.

o Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI >35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity.

• In addition, supplemented fasting is a type of very low calorie weight reduction regimen used to achieve rapid weight loss.

o The reduced calorie intake is supplemented by a mixture of protein, carbohydrates, vitamins, and minerals.

o Serious questions exist about the safety of prolonged adherence for 2 months or more to a very low calorie weight reduction regimen as a general treatment for obesity, because of instances of cardiopathology and sudden death, as well as possible loss of body protein.

 

Indications and Limitations of Coverage

 

Nationally Covered Indications

• Certain designated surgical services for the treatment of obesity are covered for Medicare beneficiaries who have a BMI >35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. See §100.1.

 

Nationally Noncovered Indications

• Treatments for obesity alone remain non-covered.

• Supplemented fasting is not covered under the Medicare program as a general treatment for obesity (see section D. below for discretionary local coverage).

 

Other

• Where weight loss is necessary before surgery in order to ameliorate the complications posed by obesity when it coexists with pathological conditions such as cardiac and respiratory diseases, diabetes, or hypertension (and other more conservative techniques to achieve this end are not regarded as appropriate), supplemented fasting with adequate monitoring of the patient is eligible for coverage on a case-by-case basis or pursuant to a local coverage determination.

• The risks associated with the achievement of rapid weight loss must be carefully balanced against the risk posed by the condition requiring surgical treatment.

• (This NCD last reviewed February 2006.)

 

Cross Reference

• See §§100.1, 100.8, and 100.11.

 

Claims Processing Instructions

• TN 931 (Medicare Claims Processing)

 

Coverage Transmittal Link

• Http://www.cms.gov/transmittals/downloads/R54NCD.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 Obesity as an Illness (CAG-00108N) opens in new window

 

Medicare NCD Link