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National Coverage Determination (NCD) for Intensive Behavioral Therapy for Obesity (210.12)

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Benefit Category
Additional Preventive Services

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

Item/Service Description

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 therapy 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.


Indications and Limitations of Coverage

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 patient’s 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 when 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 covers:

  • 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 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 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)


Claims Processing Instructions
Transmittal Number

142

Revision History

02/2012 - Effective for claims with dates of service November 29, 2011, and later, Medicare beneficiaries with obesity (BMI andNo.8805;30 kg/m2), 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 in a primary care setting are eligible for: 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. This revision to the Medicare National Coverage Determinations Manual is a national coverage determination (NCD). NCDs are binding on all carriers, fiscal intermediaries,[contractors with the Federal government that review and/or adjudicate claims, determinations, and/or decisions], quality improvement organizations, qualified independent contractors, the Medicare appeals council, and administrative law judges (ALJs) (see 42 CFR section 405.1060(a)(4) (2005)). An NCD that expands coverage is also binding on a Medicare advantage organization. In addition, an ALJ may not review an NCD. (See section 1869(f)(1)(A)(i) of the Social Security Act.) Effective Date: 11/29/2011. Implementation Date: 03/06/2012. (TN 142) (CR7641)


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.

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