Centers for Medicare & Medicaid Services

Content Section

Publication Number

100-3

Manual Section Number

40.5

Version Number

Effective Date of this Version

2/21/2006

Implementation Date

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

B. 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.

C. Nationally Noncovered Indications

1. Treatments for obesity alone remain non-covered.

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

D. 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.

Transmittal Number

Transmittal Link

Http://www.cms.hhs.gov/transmittals/downloads/R54NCD.pdf

Revision History

10/2004 - Revised language to address coverage of particular care and services rather than definition of illness. Language change did not directly affect current Medicare coverage. Services are covered only when an integral and necessary part of a course of treatment for medical condition. Treatment unrelated to such medical condition remains non-covered. Effective and implementation dates 10/01/2004. (TN 23) (CR 3502)

04/2006 - Revised language to include reference to covered surgical procedures. Effective date: 02/21/2006 (TN 54) CR5013

Implementation date:

05/30/2006: Physician claims billed to the Carrier
10/02/2006: Hospital claims billed to the FI

Claims Processing Instructions

TN 931 (Medicare Claims Processing)

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)

Other Versions

Treatment of Obesity - Version 2, Effective between 10/01/2004 - 02/21/2006
Treatment of Obesity - Version 1, Effective between 01/01/1966 - 10/01/2004

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