(Medicare National Coverage Determinations Manual)

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)(i)  (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) );  C. Nationally Non -Covered Indications   Unless specifically covered in this NCD, any other NCD, or in statute, preventive services are non-covered by Medicare.   D. Other  Medicare coinsurance and Part B deductible are waived for these preventive services.   HIBC to prevent STIs may be provided on the same date of services as an annual wellness visit, evaluation and management (E&M) service, or during the global billing period for obstetrical car, but only one HIBC may be provided on any one date of service.  See the claims processing manual for further instructions on claims processing.  For services provided on an annual basis, this is defined as a 12- month period.  (This NCD last reviewed November 2011.)   210.11  Intensive Behavioral Therapy for Cardiovascular Disease (CVD) (Effective November 8, 2011)  (Rev. 137, Issued: 11- 23-11, Effective: 11 -08-11, Implementation: 12- 27-11 non -shared system edits, 04- 02-12 shared system edits, 07- 02-12 CWF/HICR/MCS MCDST)   A. General   Cardiovascular disease (CVD) is the leading cause of mortality in the United States.  CVD, which is comprised of hypertension, coronary heart disease (such as myocardial infarction and angina pectoris), heart failure and stroke, is also the leading cause of hospitalizations.  Although the overall adjusted mortality rate from heart disease has declined over the past decade, opportunities for improvement still exist.  Risk factors for CVD include being overweight, obesity, physical inactivity, diabetes, cigar ette smoking, high blood pressure, high blood cholesterol, family history of myocardial infarction, and older age.   Under 1861(ddd) of the Social Security Act (the Act), the Centers for Medicare & Medicaid Services (CMS) has the authority to add coverage of additional preventive services through the National Coverage Determination (NCD) process if certain statutory req uirements are met. Following its review, CMS has determined that the evidence is adequate to conclude that intensive behavioral therapy for CVD is reasonable and necessary for the prevention or early detection of illness or disability, is appropriate for i ndividuals entitled to benefits under Part A or enrolled under Part B, and is comprised of components that are recommended with a grade of A or B by the U.S. Preventive Services Task Force (USPSTF).  B. Nationally Covered Indications   Effective for claims with dates of service on or after November 8, 2011, CMS covers intensive behavioral therapy for CVD (referred to below as a CVD risk reduction visit), which consists of the following three components:    encouraging aspirin use for the primary prevention of CVD when the benefits outweigh the risks for men age 45- 79 years and women 55- 79 years;    screening for high blood pressure in adults age 18 years and older; and    intensive behavioral counseling to promote a healthy diet for adults with hyperlipidemia, hypertension, advancing age, and other known risk factors for cardiovascular - and diet -related chronic disease.   We note that only a small proportion (about 4%) of the Medicare population is under 45 years (men) or 55 years (women), therefore the vast majority of beneficiaries should receive all three components.  Intensive behavioral counseling to promote a healthy diet is broadly recommended to cover close to 100% of the population due to the prevalence of known risk factors.   Therefore, CMS covers one, face -to-face CVD risk reduction visit per year for Medicare beneficiaries 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 prima ry care practitioner in a primary care setting.   The behavioral counseling intervention for aspirin use and healthy diet should be consistent with the Five As approach that has been adopted by the USPSTF to describe such services:    Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.   Advise :  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.   Agree:  Collaboratively select appropriate treatment goals and methods based on the patients interest in and willingness to change the behavior.    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.    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 the purpose of this NCD, a primary care setting is defined as the 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 purpose of  this NCD, a primary care physician and primary care practitioner are defined consistent with existing sections of the 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 practitioner. The 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)).   C. Nationally Non -Covered Indications   Unless specifically covered in this NCD, any other NCD, or in statute, preventive services are non-covered by Medicare.   D. Other  Medicare coinsurance and Part B deductible are waived for this preventive service.   (This NCD last reviewed November 2011.)   210.12   Intensive Behavioral Therapy for Obesity (Effective November 29, 2011)  (Rev. 142, issued: 02- 03-12, Effective: 11 -29-11, Implementation: 03- 06-12)  A. 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 thera py for obesity.  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.  In the Medicare population over 30% of men and women are obese.  Obesity is directly or indirectly associated with many chronic diseases including cardiovascular disease, musculoskeletal conditions and diabetes.   B. 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:   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 wh en 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 cover s:   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 need s, 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 practitioner The 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))   C. Nationally Non -Covered Indications   All other indications remain non- covered.   D. Other   Medicare coinsurance and Part B deductible are waived for this service   (This NCD last reviewed November 2011)