Obesity may be caused by medical conditions such as hypothyroidism, Cushing's disease, 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 services when such services are an integral and necessary part of a course of treatment for one of these illnesses. Certain designated surgical services for the treatment of obesity are covered for members who have a BMI ≥35, have at least one comorbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity.

Bariatric surgery procedures are performed to treat comorbid conditions associated with morbid obesity. Two types of surgical procedures are employed. Malabsorptive procedures divert food from the stomach to a lower part of the digestive tract where the normal mixing of digestive fluids and absorption of nutrients cannot occur. Restrictive procedures restrict the size of the stomach and decrease intake. Surgery can combine both types of procedures.

Treatment of Obesity

Obesity is not in and of itself sufficient to support medical necessity.  The patient must have morbid obesity and a V code diagnoses which describes a BMI ≥35 and another condition which was either caused by or aggravated by the obesity.  Morbid obesity and a V code diagnoses which describes a BMI ≥35, and another diagnosis code that supports medical necessity as indicated in this policy must be reported on the claim.

Type 2 diabetes mellitus (T2DM) is a comorbidity for purpose of this policy.

Supplemental Fasting

Supplemental 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 two months or more to a very low calorie weight reduction regimen as a general treatment of obesity, because of instances of cardiopathology and sudden death, as well as possible loss of body protein. Therefore, supplemented fasting is not covered as a general treatment for obesity.

In cases 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 covered on an individual consideration basis. The risks associated with the achievement of rapid weight loss must be carefully balanced against the risk posed by the condition requiring surgical treatment.

Bariatric Surgery for the Treatment of Morbid Obesity
The following designated surgical services for the treatment of obesity are covered for members if:

1. The individual has a body-mass index ≥35
2. The individual has at least one comorbidity related to obesity; and
3. The individual has been previously unsuccessful with medical treatment for obesity.

These procedures are only covered when performed at facilities that are:

1. Certified by the American College of Surgeons as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or
   
2. Certified by the American Society of Bariatric Surgery as a Bariatric Surgery Center of Excellence (program standards and requirements in effect on February 15, 2006.

A list of approved facilities and their approval dates are listed and maintained on the CMS Coverage Web site at http://www.cms.hhs.gov/center/coverage.asp.and published in the Federal Register.

Noncovered Indications

Nationally Non-Covered Indications

1. Treatments for obesity alone are non-covered.
2. Supplemental fasting is not covered as a general treatment for obesity.
3. Open and laparoscopic RYGBP, open and laparoscopic BPD/DS and LAGB are non-covered for members who have a BMI <35 and T2DM.
   

The evidence is not adequate to conclude that the following bariatric surgery procedures are reasonable and necessary.  Therefore, they are non-covered.  A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

• Open adjustable gastric banding (43999)
• Open and laparoscopic sleeve gastrectomy (43775, 43999)
• Open and laparoscopic vertical banded gastroplasty (43842, 43659)
• Gastric Balloon (43999) (Per NCD Section 100.11) 
• Intestinal Bypass Surgery (43999) (Per NCD Section 100.8) - the safety of intestinal bypass surgery for treatment of obesity has not been demonstrated. Severe adverse reactions such as steatorrhea, electrolyte depletion, liver failure, arthralgia, hypoplasia of bone marrow, and avitaminosis have sometimes occurred as a result of this procedure. It does not meet the reasonable and necessary provisions of § 1862 (a)(1) of the Act.  Intestinal bypass is not a covered service.

The treatment of morbid obesity unrelated to such medical conditions listed above is not considered reasonable and necessary and is not covered under the program. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Place of Service: Inpatient

Documentation Requirements

The documentation must support the medical necessity of the service and be available upon request.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Provider News

04/2012, Medicare Advantage Medical Policy N-131 to include place of service designation

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

Medicare Internet On-Line Manual Pub. 100-3, Chapter 1, Section 40.5, 100.1, 100.8, 100.11, 100.14

Medicare Internet On-Line Manual Pub. 100-04

Transmittal 23, Change Request 3502

Transmittal 54, Change Request 5013

Transmittal 931, Change Request 5013

Transmittal 1728, Change Request 6419

Transmittal 100, Change Request 6419

(Applicable to the medical treatment of obesity and procedure codes 43644, 43645, 43770-43774, 43843-43848, and 43886-43888)

Covered Diagnosis Codes

Report 278.01 and one of the following diagnoses to support a BMI of > 35 or morbid obesity: