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B. Nationally Covered Indications

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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:  

  1. 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);
  2. Dietary (nutritional) assessment; and
  3. 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:  

  1. **Assess** : Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. **Advise** : Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. **Agree** : Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.
  4. **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.
  5. **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:  

  * One face-to-face visit every week for the first month;
  * One face-to-face visit every other week for months 2-6;
  * 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. 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. This determination
must be documented in the physician office records for applicable
beneficiaries consistent with usual practice. 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 who are accountable for addressing a large
majority of personal health care needs, developing a sustained partnership
with patients, and 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)).

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.

1833(x)(2)(A)  
Primary care practitionerThe term primary care practitioner means an
individual  
(i) who  
(I) 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; or  
(II) is a nurse practitioner, clinical nurse specialist, or physician
assistant (as those terms are defined in section 1861(aa)(5))

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C. Nationally Non-Covered Indications

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All other indications remain non-covered.

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D. Other

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Medicare coinsurance and Part B deductible are waived for this service

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(This NCD last reviewed November 2011)

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