On November 29, 2011, a final coverage decision memorandum was passed by the Center for Medicare and Medicaid Services (CMS) for intensive behavioral therapy for obesity. These services have been deemed reasonable and necessary for the prevention or early detection of illness and/or disability and are appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

CMS specified in the decision memo that it will cover:

• One face-to-face visit every week for the first month in the primary care setting;
• 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 Medicare beneficiary meets the 3kg (6.7 lbs) weight loss requirement.

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, Medicare beneficiaries must have achieved a reduction in weight of at least 3kg (6.7 lbs) over the course of the first six months of intensive therapy. This determination must be documented in the physician office medical records for applicable Medicare beneficiaries consistent with usual practice. For Medicare beneficiaries who do not achieve a weight loss of at least 3kg (6.7 lbs) during the first six months of intensive therapy, a re-assessment of their readiness to change and Body Mass Index (BMI) is appropriate after an additional six month period.

The memo defined intensive behavioral therapy for obesity as consisting of

• Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (kg/m2)
• A dietary (nutritional) assessment; and
• Intensive behavioral counseling and behavioral therapy that promotes sustained weight loss through high-intensity interventions on diet and exercise.

According to CMS, all such interventions should be consistent with the 5-A framework highlighted by the U.S. Preventive Services Task Force (USPSTF), which include:

• Assessing: Asking about/assessing behavioral health risks and factors affecting choice of behavior change goals/methods.
• Advising: Giving clear, specific and personalized behavior change advice, including information about personal health harms and benefits.
• Agreeing: Collaboratively agreeing on appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
• Assisting: Using behavior change techniques (e.g., self-help and/or counseling) to assist the patient to achieve agreed-upon goals by acquiring the skills, confidence and social/environmental supports for behavior change, supplemented with adjunctive medical treatments, when appropriate.
• Arranging: Scheduling 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 the purposes of this decision memorandum, a primary care setting is defined as:

• 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.

Note: 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.

While this benefit is limited to primary care practitioners and primary care settings, it does not preclude primary care practitioners from screening beneficiaries for obesity and referring those who screen positive with a BMI ≥ 30 kg/m2 to other practitioners and/or settings for intensive multicomponent counseling; however coverage remains only in the primary care setting.

The following is a link for more information on this CMS program memorandum.