Incident to a physician's professional Service
This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
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 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.
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
Services performed in connection with the treatment of obesity are covered by Medicare when such services are an integral and necessary part of a course of treatment for diseases such as hypothyroidism, Cushing’s disease, hypothalamic lesions, cardiovascular diseases, respiratory diseases, diabetes, and hypertension.
C. Nationally Noncovered Indications
1. The treatment of obesity unrelated to such a medical condition (see section B. above) is not considered reasonable and necessary and is not covered under the Medicare program.
2. Supplemented fasting is not covered under the Medicare program as a general treatment for obesity (see section D. below for discretionary local coverage).
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 local coverage determination through individual contractor discretion. 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 September 2004.)
See §§100.1, 100.8, and 100.11.