[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.