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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
4
Effective Date of this Version
09/24/2013
Ending Effective Date of this Version
Implementation Date
12/17/2013
Implementation QR Modifier Date

Description Information

Benefit Category
Incident to a physician's professional Service
Physicians' Services


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

Please note section 40.5 has been removed from the NCD Manual and incorporated into NCD 100.1.
Cross Reference
See §§100.1, 100.8, and 100.11.
Claims Processing Instructions

Transmittal Information

Transmittal Number
158
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R158NCD.pdf
Revision History

12/2013 - (Rev.158, Issued: 12-23-13, Effective: 09-24-13, Implementation: 12-17-13)

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 You are here
Treatment of Obesity 3 02/21/2006 - 09/24/2013 View
Treatment of Obesity 2 10/01/2004 - 02/21/2006 View
Treatment of Obesity 1 01/01/1966 - 10/01/2004 View
CPT Copyright Statement
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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