Medicare Coverage for Obesity to Include Intensive Behavioral Therapy

Over 30 percent of Medicare beneficiaries are estimated to be obese; having a body-mass index (BMI) of equal to or greater than 30. This fact, in conjunction with a correlation that obesity is associated with many chronic diseases such as cardiovascular disease and diabetes, lead to recent approval by Medicare for coverage of intensive behavioral therapy for obesity, according to a CMS press release.

Covered Services and Practitioners

A decision memo issued by CMS describes the services covered, the practitioners who may bill for services, and the care setting in which services maybe provided.

Intensive behavioral therapy includes:

  •  (1) a screening for obesity,
  •  (2) a dietary assessment, and
  • (3) intensive behavioral counseling and behavioral therapy to promote sustained weigh loss though high intensity intervention on diet and exercise.

Qualified primary care physicians or other primary care practitioners may be reimbursed by Medicare for one face-to-face visit every week during the first month; one face-to-face visit every other week during months 2 through 6; and possibly one face-to-face visit every month during months 7 to 12 if the beneficiary has lost at least 6.6 lbs in the first six months of coverage for each beneficiary that is determined to be obese.  The face-to-face meeting has to be provided in a primary care setting.

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, according to CMS.

A primary care physician is a physician who is a general practitioner, family practice practitioner, general internist, or obstetrician or gynecologist.  A primary care practitioner includes a nurse practitioner, clinical nurse specialist, or physician assistant.

While this benefit is limited to being billed by a primary care practitioner or physician, nothing prevents primary care practitioners from screening beneficiaries for obesity and referring those who qualify to other practitioners and/or settings for intensive multi-component counseling as long as the visit is provided in a  primary care setting.  This wording was included in CMS’ decision memo presumably to address the concern that physicians may not have the time or training to provide the face-to-face visits.

Benefit of Coverage

The U.S. Preventive Services Task Force (USPSTF) found that there was fair to good evidence that high-intensity counseling about diet and exercise, with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese. Although the USPSTF did not find direct evidence that behavioral interventions lower mortality or morbidity from obesity, the USPSTF concluded that changes in intermediate outcomes, such as improved glucose metabolism, lipid levels, and blood pressure, from modest weight loss provide indirect evidence of health benefits.

Coverage for this level of therapy for obesity was approved because it received a grade B recommendation from the USPSTF and preventive services with that grade are eligible for coverage under Section 4105 of the  Patient Protection and Affordable Care Act (PPACA)(P.L. 111-148).