Medicare Compliance & Reimbursement

CMS Administrator says "medical science will decide."

Though the ground hasn't broken yet, a new coverage determination from the Centers for Medicare & Medicaid Services could be the first tremor.

A new policy unveiled July 16 by Health and Human Services Secretary Tommy Thompson clarifies CMS' position on obesity as a disease, rather than merely a co-morbidity. If medical and scientific evidence concurs, the move could open the doors to coverage of obesity-related medical interventions down the road.

Confusing language in the Coverage Issues Manual which classified obesity as "not an illness" will be replaced. The CIM, explains CMS, was intended to address the coverage of services -- not the definitions of diseases.

The national coverage determination will now take into consideration that obesity could also be caused by conditions such as hypothyroidism, Cushing's disease and hypothalamic lesions.

CMS is calling for the submission of published, clinical trial data that demonstrate that obesity-related treatments improve the health of Medicare beneficiaries.

"We encourage and we're expecting requests to review scientific evidence evaluating the benefits of a range of treatments for obesity in the Medicare population," says CMS Chief Medical Officer Dr. Sean Tunis.

The Medicare Coverage Advisory Committee plans to meet in fall 2004 to evaluate whether evidence supports bariatric surgery to reduce the risk of certain diseases. To read the coverage decision, go to http://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=57.

Lesson Learned: With enough medical and scientific evidence, Medicare reimbursement for anti-obesity services could soon be a reality.