Health Insurance Coverage for Weight Loss
Health Insurance Coverage for Weight Loss Criteria According to updated Aetna Policy Bulletin
Information on Health Insurance Coverage for Weight Loss based on Aetna Policy..
“Note: Many Aetna plan benefit descriptions specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion. Please check benefit plan descriptions for details.
Aetna considers the following medically necessary treatment of obesity when criteria are met:
Weight reduction medications, and
Clinician supervision of weight reduction programs.”
Interestingly, taking weight reduction medications comes with drawbacks. In fact, Aetna policy bulletin on health insurance coverage for weight loss states the following:
“Weight loss due to weight reduction medication use is generally temporary. In addition, the potential for development of physical dependence and addiction is high. Because of this, their use to aid in weight loss is not regarded as therapeutic, but rather involves a risk/benefit ratio, which makes it medically inappropriate in most cases.”
So if you are a health minded individual, why not take a more holistic route? The policy criteria calls for medications with high addiction likelihood and the weight loss is generally temporary! So, why risk addiction for temporary weight loss?
Policy bulletin answers the question accordingly:
“Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity. For such individuals, use of weight reduction medication may need to be chronic.”
Food addicts are known to suffer withdrawals much like a drug addict. Couple that with common side effects of the 8 FDA approved weight loss medications such as agitation, anxiety, confusion, dizziness, irritability, nervousness, restlessness, insomnia, mood or other mental changes. That is just the short list. Personal interactions at home and the workplace become more challenging under these conditions and relationships suffer. Wouldn’t it be ideal just to immerse oneself in the business of weight loss without dealing with daily responsibilities and distractions? Aetna policy on insurance coverage for weight loss states:
“Hospital confinement is considered not medically necessary for a weight reduction program.”
The policy criteria and exclusions make going away to a weight loss camp a healthier approach. There you can focus on your weight loss goals without offending family, friends, or coworkers. Instead, you are supported by those pursuing the same goals in a protected environment.
Common exclusions on insurance coverage for weight loss
Note: Under most benefit plans, the following services and supplies for weight reduction are specifically excluded from coverage
- Exercise programs or use of exercise equipment
- Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, or phytotherapy)
- Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.
Criteria for health insurance coverage for weight loss
Weight Reduction Medications:
Weight reduction medications are considered medically necessary for members who have failed to lose at least one pound per week after at least 6 months on a weight loss regimen that includes a low calorie diet, increased physical activity, and behavioral therapy, and who meet either of the following selection criteria below:
Member has a body mass index** (BMI) greater than or equal to 30 kg/m² **BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm ; or
- Member has a BMI greater than or equal to 27 kg/m² with any of the following obesity-related risk factors considered serious enough to warrant weight loss medication:
Coronary heart disease
HDL cholesterol less than 35 mg/dL, or
LDL cholesterol greater than or equal to 160 mg/dL, or
- Triglycerides greater than or equal to 400 mg/dL
Hypertension (systolic blood pressure [SBP] higher than 140 mm Hg or diastolic blood pressure [DBP] higher than 90 mm Hg on more than one occasion)
Obstructive sleep apnea
- Type 2 diabetes mellitus.
Clinician Supervision of Weight Reduction Programs:
Up to a combined limit of 26 individual or group visits by any recognized provider per 12-month period are considered medically necessary for weight reduction counseling in adults who are obese (as defined by BMI ≥ 30 kg/m2**). The number of medically necessary visits for obese children are left to the discretion of the member’s physician.
** For a simple and rapid calculation of BMI, please click below and it will take you to the Obesity Education Initiative: BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm
The following services are considered medically necessary for the evaluation of overweight or obese individuals:
Complete blood count
Comprehensive history and physical examination
Dexamethasone suppression test and 24-hour urinary free cortisol measures if symptoms suggest Cushing’s syndrome.
Electrocardiogram (EKG) — adult
- Glucose tolerance test (GTT)
Hand x-ray for bone age — child
Lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides)
Metabolic and chemistry profile (serum chemistries, liver tests, uric acid) (SMA 20)
Thyroid function tests (T3, T4, TSH)
Very Low Calorie Diets (VLCD):
For obese members who have been prescribed a very low calorie diet (VLCD) (less than 799 Kcal/day) (e.g., Optifast, Medifast), the following services are considered medically necessary for up to 16 weeks after initiation of the VLCD:
EKG after 50 lbs of weight loss; and
Lipid profile at the beginning and end of the VLCD program; and
Serum chemistries and liver function tests (SMA 20) weekly during the rapid weight loss phase of the VLCD, then every 2 weeks thereafter up to 16 weeks.
Note: VLCDs extending beyond 16 weeks are subject to medical review to determine if additional services are medically necessary.
Notes: Prepackaged food supplements or substitutes and grocery items are generally excluded from coverage under most benefit plans. Diagnostic tests required by, for or as a result of non-covered weight loss programs (e.g., those not requiring physician supervision) are not covered. Please check benefit plan descriptions for details.
The following interventions are considered experimental and investigational for weight reduction:
Acupuncture for weight loss
Body plethysmography (diagnostic study)
Dual-energy X-ray (DEXA) body composition (diagnostic study)
- Gastric electrical stimulation (see CPB 0678 – Gastric Pacing and Gastric Electrical Stimulation)
- Human chorionic gonadotropin (HCG) or vitamin injections for weight loss
Indirect calorimetry (e.g., ReeVue Indirect Calorimeter) (diagnostic study)
Whole body calorimetry and composition is considered experimental and investigational for weight reduction and other indications.
Hospital confinement is considered not medically necessary for a weight reduction program.
Note: Under most benefit plans, the following services and supplies for weight reduction are specifically excluded from coverage (please check benefit plan descriptions for details)
Exercise programs or use of exercise equipment
Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid protein meals, NutriSystem pre-packaged foods, or phytotherapy), see CPB 0061 – Nutritional Support
Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.
For Aetna’s clinical policy on surgical management of obesity, see CPB 0157 – Obesity Surgery.
Health Insurance for Weight Loss Camp -Criteria
Although HMOs, health maintenance organizations, will not pay for weight loss camps or programs, PPOs, preferred provider organizations, may provide coverage when a physician has indicated the weight-loss program. This applies to patients who fail to maintain a BMI below 27 and/or have obesity related medical conditions.
Tax Deduction for Weight Loss Camp
The 2002-19 IRS ruling has recognized obesity as a disease, allowing tax deduction for costs specifically associated with the medical services. Ask the weight-loss camp if it can detail the invoice, and be sure to consult a tax advisor.
Health Savings Account
A HSA health savings account is a great way to pay out-of-pocket medical expenses with pre-tax dollars. Again, the weight loss treatment must be prescribed by a physician. If you haven’t already set up your account, it is always a good idea to have one.