Treatment of Obesity

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.

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.)

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)

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