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Medicare Revises Obesity Coverage Policy

Policy opens door to coverage of anti-obesity interventions 

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A simple revision to a government policy manual may at last make it possible for seniors and disabled Americans to have treatments for diseases related to obesity covered under Medicare.

The revised policy announced by the Department of Health and Human Services (HHS) removes language in the Medicare Coverage Issues Manual stating that obesity is not an illness. This step allows members of the public to request that Medicare review medical evidence to determine whether specific treatments related to obesity would be covered by Medicare.

"Obesity is a critical public health problem in our country that causes millions of Americans to suffer unnecessary health problems and to die prematurely. Treating obesity-related illnesses and complications adds billions of dollars to the nation's health care costs," said HHS Secretary Thompson during testimony before the Senate Appropriations Subcommittee on Labor, Health and Human Services and Education. "With this new policy, Medicare will be able to review scientific evidence in order to determine which interventions improve health outcomes for seniors and disabled Americans who are obese and its many associated medical conditions."

By law, Medicare covers specified medically necessary services for illness and injury. The prior manual language, because it stated that obesity was not an illness, could prevent Medicare from covering treatments for diseases related to obesity.

"From the standpoint of Medicare coverage and the health of our beneficiaries, the question isn't whether obesity is a disease or a risk factor. What matters is whether there's scientific evidence that an obesity-related medical treatment improves health," said CMS Administrator Mark McClellan, M.D., Ph.D. "This change in Medicare's coverage policy puts the focus on public health. The medical science will now determine whether we provide coverage for the treatments that reduce complications and improve quality of life for the millions of Medicare beneficiaries who are obese."

The new policy is not expected to have an immediate impact on Medicare coverage. It does not affect the existing Medicare coverage of treatments of diseases resulting in or made worse by obesity, in particular currently covered surgical treatments for morbidly obese individuals.

However, as requests for coverage of obesity treatments are made by the public, Medicare will implement timely review of the scientific evidence, using the coverage determination procedures established in 1999 and modified by the Medicare Modernization Act of 2003. Detailed information on this process can be found on the Medicare coverage Web site www.cms.gov/coverage. Essential to this process is 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," said CMS Chief Medical Officer Sean Tunis, M.D. "As a first step, we expect to convene our Medicare Coverage Advisory Committee in the fall to evaluate the evidence on obesity-related surgical procedures that may reduce the risk of heart disease and other illnesses."

More information about this major Medicare policy revision can be found at http://www.cms.hhs.gov/ncdr/searchdisplay.asp?id=57

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