Obesity as an Illness

Request accepted following review of formal request letter and corresponding submitted literature received on September 6. Decision will be due on December 14, 2001.

Additional time is needed for internal agency review of material. We will extend the deadline to January 31, 2002.

We are continuing to review material related to treatments for the condition of obesity. We will extend the deadline to February 28, 2002.

We are continuing to review material. We will extend the deadline to May 30, 2002

We are continuing to review material concerning the topic of obesity to address whether or not obesity is a disease under the Medicare program. Because a national coverage determination must address whether or not a particular item or service is covered nationally under title XVIII, we invite the public to submit evidence or comments concerning potential items or services that fall within Medicare benefit categories that would be used to treat obesity. As part of this process, CMS intends to commission a technology assessment. The issues to be addressed by the technology assessment and a tentative due date for the technology assessment will be posted on this site once finalized.

CMS opened this NCD to clarify the confusion resulting from statements in the current Coverage Issues Manual that indicated that obesity is not an illness. Because the Coverage Issue Manual is intended to address the coverage of particular care and services, rather than the definition of illness, we do not believe it is appropriate for the manual to address this issue. Furthermore, our review of current literature indicates that there is no general agreement on the classification of obesity as an illness. For purposes of the Coverage Issues Manual, the critical issue is not the classification of obesity but whether particular items or services are reasonable and necessary. (The Technology Assessment that we are posting today addresses some of these services.) Therefore, we are removing the confusing language from the coverage manual. This clarification results in the following language in the Coverage Issues Manual:

35-26 TREATMENT OF OBESITY

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. Services in connection with the treatment of obesity are covered services when such services are an integral and necessary part of a course of treatment for one of these medical conditions. However, program payment may not be made for treatment of obesity unrelated to such a medical condition since treatment in this context has not been determined to be reasonable and necessary.

This does not change any of the current coverage determinations. Treatments for obesity alone remain non-covered and coverage for treatments of diseases resulting in or exacerbated by obesity remain unchanged. Individuals wishing to modify current coverage determinations are encouraged to request a National Coverage Determination on each specific treatment. Guidance on that process can be found at http://www.cms.hhs.gov/coverage/8a.asp. In addition, CMS anticipates convening a Medicare Coverage Advisory Committee meeting in the Fall 2004 to discuss bariatric surgery. This NCD is now closed.