CMS Pub. 100-03, ch. 1, § 210.12

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.

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)