DESCRIPTION
The purpose of this document is to establish criteria for determining when moderate and intensive, multicomponent intervention visits should be extended beyond the standard limit of 12 visits per annual benefit period. Examples of moderate and intensive multicomponent interventions include, but are not limited to, diet and nutrition counseling, management activities such as setting weight-loss goals, increasing physical activity, addressing barriers to change, self-monitoring, and lifestyle counseling.
The U. S. Preventive Services Task Force (USPSTF) found adequate evidence that multicomponent, moderate- to high-intensity interventions for obese children and adolescents age 6 years and older can effectively yield short-term (up to 12 months) improvements in weight status. The USPSTF also found adequate evidence that intensive, multicomponent interventions for obese adults can lead to an average weight loss of 4 to 7 kg (8.8 to 15.4 lbs.) in the first year. These interventions can also improve glucose tolerance and other physiologic risk factors for cardiovascular disease and improve long-term health.
POLICY
The extension of moderate or intensive, multicomponent intervention visits for obesity, beyond the initial 12 visits and up to a maximum of 26 visits per annual benefit period, is considered medically necessary and appropriate if ALL of the following criteria are met:
The interventions take place in a face-to-face, individual visit setting (i.e., not a group setting)
The individual met ANY ONE of the following during their initial / first visit:
They were less than 18 years of age and their age- and gender-specific BMI was equal to or greater than (>) the 95th percentile
They were eighteen (18) years of age or older and their BMI was equal to or greater than (>) 30 kg/m2
There is documentation that the individual has been compliant (e.g., kept appointments, has actively participated) with the moderate or intensive, multicomponent interventions to date
There is documentation in the medical records of progress (i.e., weight loss) during the initial 12 visits of moderate– to high-intensity interventions for individuals less than 18 years of age, or intensive interventions for individuals 18 years of age or older.
SOURCES
U. S. Preventive Services Task Force. (2012). Screening for and management of obesity in adults: U.S. preventive services task force recommendation statement. Annals of Internal Medicine, 157 (5), 373-378.
U. S. Preventive Services Task Force. (2010). Screening for obesity in children and adolescents: U. S. preventive services task force recommendation statement. Pediatrics, 125 (2), 361-367.
United States Department of Labor. Employee Benefits Security Administration. FAQS about affordable care act implementation (Part XXIX) and mental health parity implementation. (October 23, 2015). Retrieved May 18, 2016 from https://www.dol.gov/ebsa/faqs/faq-aca29.html.
ORIGINAL EFFECTIVE DATE: 6/15/2016
MOST RECENT REVIEW DATE: 2/15/2024
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This document has been classified as public information.