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National Coverage Determination (NCD)

Treatment of Obesity

40.5

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Tracking Information

Publication Number
100-3
Manual Section Number
40.5
Manual Section Title
Treatment of Obesity
Version Number
3
Effective Date of this Version
02/21/2006
Ending Effective Date of this Version
09/24/2013
Implementation Date
05/30/2006
Implementation QR Modifier Date

Description Information

Benefit Category
No Benefit Category


Please 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.
Claims Processing Instructions

Transmittal Information

Transmittal Number
54
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R54NCD.pdf
Revision History

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

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)
Other

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.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Treatment of Obesity 4 09/24/2013 - N/A View
Treatment of Obesity 3 02/21/2006 - 09/24/2013 You are here
Treatment of Obesity 2 10/01/2004 - 02/21/2006 View
Treatment of Obesity 1 01/01/1966 - 10/01/2004 View
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CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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