The Coverage Issues Manual (CIM) states in sections 35-26 and 35-33 that "obesity is not considered an illness . . ." The sections do not relate specifically to obesity, but rather, to treatments which are currently noncovered. There is a growing body of literature that suggests that obesity may be considered a disease and not just a co-morbidity. This request looks at removing the current language in the CIM that states obesity is not an illness.
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.
