MEDICAL POLICY POLICY TITLE NUTRITIONAL COUNSELING FOR THE TREATMENT OF OBESITY
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1 Original Issue Date (Created): July 1, 2002 Most Recent Review Date (Revised): Effective Date: October 27, 2009 October 31, RETIRED I. POLICY Nutritional counseling may be considered medically necessary when provided to adult or pediatric diabetics. Two outpatient nutritional counseling sessions per year may be considered medically necessary for non-diabetic children ages 0-18 diagnosed with overweight or obesity and non-diabetic adults with a BMI of thirty or more. Providers of this nutritional counseling must be registered dieticians or nutritional counselors only. Nutritional counseling may be performed in a hospital outpatient setting by a certified dietician/nutritionist. Nutritional counseling is excluded for all conditions except those listed above. Components (i.e., nutritional counseling, nutritional supplements, commercial weight loss programs, exercise equipment, or gym memberships) of the medical treatment of obesity and morbid obesity are excluded, except for nutritional counseling for diabetics and overweight or obese children. Cross-references MP Ketogenic Diet As a Treatment of Refractory Epilepsy MP Diabetic Self-Management Training Program II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below [N] CHIP [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [Y] SpecialCare*** [N] POS [Y] FEP PPO** Page 1
2 * Morbid obesity is defined by Medicare as a weight that is at least 100 pounds or 100% over ideal weight or a body mass index (BMI) of 35 or greater. The medical nutrition therapy (MNT) benefit is a completely separate benefit from the diabetic self-management training (DSMT) benefit. However, members are not eligible to receive both DSMT and MNT on the same date of service. Three (3) hours of MNT are eligible for coverage in the initial calendar year. Two (2) hours of follow-up MNT will be covered each year starting the calendar year following the year that the member completed the initial training. Nutritional counseling is covered for renal disease and diabetes. Nutritional counseling is covered for obesity or morbid obesity only in the presence of a comorbid condition of diabetes or renal disease. Obesity is defined as an increase of body weight beyond the limitation of skeletal and physical requirements. Refer to Centers for Medicare and Medicaid (CMS) National Coverage Determination (NCD) 180.1, Medical Nutrition Therapy, for details. ** Nutritional counseling for up to 6 visits per year is provided when billed by a covered provider. Nutritional counseling for anorexia and bulimia is not subject to the 6-visit limitation. Dieticians and nutritionists who bill independently for nutritional counseling are covered. Children aged 5-17 whose Body Mass Index (BMI) falls in the 85 th percentile or higher and are enrolled in the Jump 4 Health Weight Management Program are entitled to receive 4 nutritional counseling visits at no cost per calendar year when using a preferred health care provider. *** Nutritional counseling for obese adults with a BMI score of thirty or more is not a covered benefit. III. DESCRIPTION/BACKGROUND Medical nutrition therapy involves assessment by a registered dietician or other health care professional functioning within the scope of his or her license. Initially an assessment of overall nutritional status is performed. This assessment includes nutritional history, current dietary intake, medication use, physical activity and discussion of available options for improving nutritional status. This is followed by an individual prescription, which may include diet, counseling, or nutritional therapy. Medical nutrition therapy is frequently integrated into treatment guidelines for a variety of chronic diseases to include cardiovascular disease, diabetes mellitus, kidney disease, eating disorders, obesity and morbid obesity, hypertension, gastrointestinal disorders, and seizures (i.e., ketogenic diet). Adult Obesity Page 2
3 Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, which may result in significant complications and a shortened life span. Clinically severe (morbid) obesity is the consistent and uncontrollable weight gain of an individual who has either of the following: A body mass index (BMI) greater than or equal to 40; or A BMI equal to associated with serious comorbid conditions. The first line of treatment for morbid obesity is dietary and life style changes. Although this strategy may be effective in some patients, frequently the weight loss is not sustainable, with only five percent (5%) to ten percent (10%) of patients maintaining the weight loss for more than a few years. Childhood Obesity In 2005, the American Medical Association (AMA), the Health Resources and Services Administration (HRSA), and the Centers for Disease Control (CDC) convened an Expert Committee to revise the 1997 childhood obesity recommendations. Their initial recommendations were released on June 6, 2007 and address assessment, prevention, and treatment of child and adolescent obesity. One of their recommendations is to assess all children for obesity at all well care visits 2-18 years. Physicians and allied health professionals should use Body Mass Index (BMI) to screen for obesity and plot the BMI on a BMI growth chart. A weight category diagnosis is then made using BMI percentile: <5 th percentile: Underweight 5 th -84 th percentile: Healthy Weight 85 th -94 th percentile: Overweight 95 th -98 th percentile: Obesity With regard to classification, the Expert Committee recommends that: a) Individuals from the ages of 2 to 18 years, with a BMI > 95th percentile for age and sex, or BMI exceeding 30 (whichever is smaller), should be considered obese. b) Individuals with BMI > 85th percentile, but < 95th percentile for age and sex, should be considered overweight, and this term replaces at risk of overweight. IV. DEFINITIONS ACT 98 OF 1998 refers to a PA state mandate that requires coverage of equipment, supplies, and outpatient self-management training and education (including medical nutrition therapy) for the treatment of insulin-dependent diabetes, and non-insulin using diabetes. Equipment and supplies include blood glucose monitors, monitor supplies, Page 3
4 insulin, injection aids, syringes, insulin infusion devices, pharmacological agents for controlling blood sugar, and orthotics. BODY MASS INDEX (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. BMI is calculated by dividing the patient s body weight (in kilograms) by height (in meters) squared. The normal BMI is twenty to twenty-five kilogram/meters squared (20-25kg/m-2). V. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. VI. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VII. REFERENCES Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics Dec;120 Suppl 4:S [Website]: Accessed August 7, Bray G. Dietary Therapy. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated June 10, [Website] : Accessed August 7, Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 40.1, Diabetes Outpatient Self-Management Training. Effective 2/27/01. CMS [Website]: Page 4
5 %3A40%2E1%3A1%3ADiabetes+Outpatient+Self%2DManagement+Training. Accessed August 7, Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) 180.1, Medical Nutrition Therapy. Effective 10/2/02. CMS [Website]: %3A180%2E1%3A1%3AMedical+Nutrition+Therapy. Accessed August 7, Kubik MY, Story M, Davey C, et al. Providing obesity prevention counseling to children during a primary care clinic visit: results from a pilot study. J Am Diet Assoc Nov;108(11): Pennsylvania State Mandate Act 98 of 1998 (Reimbursement of Diabetic Supplies Act). VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement G0108 G0109 G0270 G0271 S9449 S9452 S9470 IX. POLICY HISTORY MP CAC 5/27/03 CAC 12/14/04 CAC 3/29/05 CAC 3/28/06 CAC 3/27/07 CAC 11/27/07 CAC 11/25/08 CAC 9/29/09 Consensus Review Policy approved for retirement effective 10/31/2010. Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 5
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