Weight Reduction Medications and Programs

If a person does not lose 2 kg (4.4 lb) in the first four weeks after initiating therapy, the likelihood oflong-term response is very low. Ann Intern Med. Preventive Services Task Force. Screening forobesity in adults: Recommendations and rationale. Obesity - problems and interventions.Bloomington, MN: ICSI; February 2003.

178

136

170

401.0 - 405.99

Shekelle P, Morton S, Maglione M. 2012;108(5):832-851.

Phentermine and topiramate [Qsymia].

Acupuncture for weight loss

783.6

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)

83721

Institute for Clinical Systems Improvement (ICSI). Pharmacological approaches to weight loss inadults. Efficacy of maintenance treatment approaches for childhood overweight: A randomizedcontrolled trial. DR Bennett, ed. Weight loss medications--where do they fit in? Aust Fam Physician.Effectiveness of weight management programs in children and adolescents. Health-related quality oflife following a clinical weight loss intervention among overweight and obese adults: Interventionand 24 month follow-up effects. Screening and interventions for childhood overweight: A summary ofevidence for the US Preventive Services Task Force. In: AMA Drug Evaluations Subscription.Comparison of the BOD POD and dual energy x-ray absorptiometry in men. Christchurch, NewZealand: New Zealand Health Technology Assessment (NZHTA); 2005;4(1).

Swedish Council on Technology Assessment in Healthcare (SBU). 2010;151(19):763-773.

NHS Centre for Reviews and Dissemination (CRD). Ann Intern Med. Improvement in insulinsensitivity following a 1-year lifestyle intervention program in viscerally obese men: Contribution ofabdominal adiposity. Diet programs for weight loss in adults. Residential care for severely obesechildren in Belgium. Appetite suppressants (systemic). Brussels, Belgium: Belgian Health CareKnowledge Centre (KCE); 2006.

129

123

4'11"

192Â

Dexamethasone suppression test and 24-hour urinary free cortisol measures if symptoms suggestCushing's syndrome.

Institute for Clinical Systems Improvement (ICSI). Mosby's GenRx: The Complete Reference forGeneric and Brand Drugs. Behavioral counseling in primary care to promote physical activity:Recommendation and rationale. A systematic review of the clinical effectiveness of orlistat used forthe management of obesity. The clinical effectiveness and cost-effectiveness of sibutramine in themanagement of obesity: A technology assessment. York, UK: CRD; 2002; 7(6).

5'4"

179

81001

Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at riskof medical complications of obesity are an exception to this; for these persons, the risk of physicaldependence or other adverse effects may present less of a risk than continued obesity. Randomizedtrial of lifestyle modification and pharmacotherapy for obesity. Am J Clin Nutr. Rockville, MD: FDA;updated October 8, 2010.

Abnormal weight gain

Day P. Obesity. The medical necessity criteria set forth below do not apply to health plans thatspecifically exclude services and supplies for or related to treatment of obesity or for diet or weightcontrol. 1988;149:429-441.

Gastric electrical stimulation (see CPB 0678 - Gastric Pacing and Gastric Electrical Stimulation)

ICD-9 codes covered if selection criteria are met:

Body mass index 27.0-70 and over, adult

Ideal weights for adult women:

U.S. Therapy for obesity--today and tomorrow. 21. Int J Obes Relat Metab Disord. Stockholm,Sweden: Swedish Council on Technology Assessment in Health Care (SBU); 2002.

143

Padwal R, Li SK, Lau DC. 2012;95(2):297-308.

On October 8, 2010, Abbott Laboratories announced that that it was withdrawing its diet drugMeridia (sibutramine) from the United States, Australian and Canadian markets as a consequence ofheightened concerns that the medication can trigger heart attack or stroke, especially in patients

with underlying cardiovascular disease.

Â

Shekelle PG, Morton SC, Maglione MA, et al. Diabetes Res Clin Pract. Prepared by the SouthernCalifornia-RAND Evidence-Based Practice Center, Santa Monica, CA, under contract no. Louis, MO:Mosby; 1998.

Orozco LJ, Buchleitner AM, Gimenez-Perez G, et al. 1993;119(7 pt 2):707-713.

82533

Lipid profile at the beginning and end of the VLCD program; and

American Gastroenterological Association medical position statement on obesity. Ann Intern Med.In: BMJ Clinical Evidence. Philadelphia, PA: J.B. Chicago, IL: American Medical Association (AMA);1992: III/MET 6:7.

Note: Many Aetna plan benefit descriptions specifically exclude services and supplies for or relatedto treatment of obesity or for diet and weight control. Drugs. In addition, the potential fordevelopment of physical dependence and addiction is high. 2010;125(2):e396-e418.

162

147

145

272.0

168Â

Medium Frame

82465

187

Dixon JB. Pharmacological and surgical treatment of obesity. Government Printing Office; 1990.

Rice diet or other special diet supplements (e.g., amino acid supplements, Optifast liquid proteinmeals, NutriSystem pre-packaged foods, or phytotherapy), see CPB 0061 - Nutritional SupportÂ

Â

160

Silverstone T. Home and Garden Bulletin. 2005;142(1):56-66.

85025

Other CPT codes related to the CPB:

5'1"

5'5"

Tests with weight loss drugs have shown that initial responders tend to continue to respond, whileinitial non-responders are less likely to respond even with an increase in dosage. Â Weight loss orprevention of weight gain and morbidities were the main outcomes assessed. TechnologyAssessment Report No. Drugs. The scientific evidences for most of these plants are still incomplete.2006;4:43.

Fioravante et al (2012) evaluated nutritional status, body composition, and (REE in patients withchronic hepatitis C before and during treatment with pegylated interferon and ribavirin. This wasa prospective study with the evaluation of patients with hepatitis C virus before and after 12 weeksof treatment with pegylated interferon and ribavirin. The evaluation consisted of anthropometry(weight, height, BMI, and waist circumference), and body composition was determined bybioelectrical impedance analysis. The REE of each individual was obtained by indirectcalorimetry. To compare the 2 phases of treatment, the Wilcoxon test was used. The significancelevel was 5 %. Subjects had significant weight loss during treatment with a consequent decreasein BMI. This weight decrease was accompanied by a significant decrease in body fat and nodecrease in fat-free mass. There was a significant decrease in energy intake as assessed by 24-hour recall. However, there was no change in REE and in REE corrected for fat-free mass. Theauthors concluded that patients with hepatitis C treatment had significant weight loss and this wasnot associated with changes in energy expenditure.

130

207Â

94726

81000

Clinician Supervision of Weight Reduction Programs:

Type 2 diabetes mellitus.

81050

Borel et al (2012) conducted a prospective intervention study in 104 viscerally obese men classifiedaccording to their glucose tolerance status. They were followed for one year while participating in

a healthy eating-physician activity/exercise lifestyle modification program while their insulinsensitivity was tracked. The goals of the study were to evaluate glucose tolerance as well as toevaluate the respective contribution so fo changes in body fat distribution versus changes incardiorespiratory fitness (CRF) to the improvements in indices of plasma glucose/insulinhomeostasis. The results showed insulin sensitivity improved in assocication with decreases inbothvisceral (VAT) and subcutaneous adiposity (SAT) as well as improvement in CRF, regardless ofbaseline glucose tolerance. The results of this study also shoed that reduction in VAT wasassociated with an improvement in homeostasis model assessment of insulin resistance, whereasreduction in SAT was rather associated with improvement of the insulin sensitivity index ofMatsuda. The authors concluded that a one year lifestyle intervention improved plasmaglucose/insulin homeostasis in viscerally obese men, including those with normal glucose tolerancestatus at baseline.Â

5'2"

EKG after 50 lbs of weight loss; and

84443

Tsai AG, Wadden TA. 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.

Very Low Calorie Diets (VLCD):

Â

5'10"

Fioravante M, Alegre SM, Marin DM, et al. Weight loss and resting energy expenditure in patientswith chronic hepatitis C before and during standard treatment. Clinical Guideline 43. Ann InternMed. 14th ed. Pharmacological and surgical treatment of obesity. 1992;16(suppl 3):S81-S84.

For obese members who have been prescribed a very low calorie diet (VLCD) (less than 799Kcal/day) (e.g., Optifast, Medifast), the following services are considered medically necessary for upto 16 weeks after initiation of the VLCD:

97802

Electrocardiogram (EKG) -- adult

Borel AL, Nazare JA, Smith J, et al. Health Technol Assess. 2001;5(18):1-81.

783.1

The following interventions are considered experimental and investigational for weight reduction:

Jarvis M, McNaughton L, Seddon A, Thompson D. The acute 1-week effects of the Zone diet onbody composition, blood lipid levels, and performance in recreational endurance athletes. JStrength Cond Res. 2002;16(1):50-57.

Ideal Weight Chart:

142

The following medications have been approved by the FDA for weight reduction:

S9452

Jain A. The large market for plant remedies has resulted in an array of unauthorized products ormarketed as dietary supplements and, at the same time, no reliable pharmaceutical-grade productsare registered for this purpose.

5'9"

Institute for Clinical Systems Improvement (ICSI). Diabetes has historically been treated with plantsor plant-derived formulations in different cultures, mainly in China, Asia and India. Under theseplans, claims for weight loss drugs will be denied based on this exclusion. For members whosemedical policies do not exclude weight reduction medications or services and supplies for or relatedto weight reduction programs, Aetna covers these drugs under the medical benefit, not thepharmacy benefit. 290-02-0003. Health Technol Assess. Evidence Report/Technology AssessmentNo. 2004;79(4):529-536.

82530

HDL cholesterol less than 35 mg/dL, or

Pineau JC, Guihard-Costa AM, Bocquet M. Long-term weight loss: The effect of pharmacologicagents. In: Introductory Nutrition and Diet Therapy. 2nd ed. Metabolism.  There is, however, aneed for longer-term outcomes on obesity and associated morbidities following a VLED. London, UK:NICE; 2001.

83718

164

Small Frame

136

166

Complete blood count

Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits withcontrolled-release phentermine/topiramate in obese and overweight adults (SEQUEL): Arandomized, placebo-controlled, phase 3 extension study. Accessed September 21, 2004.

94690

164

135

4'10"

Weight Watchers, Jenny Craig, Diet Center, Zone diet, or similar programs.

83719

6'0"

United States Pharmacopeial Convention, Inc. Obes Rev. Other drugs listed in this policy arecontraindicated in the following conditions: hypertension, atherosclerosis, coronary artery disease,and stroke.

McTigue K, Harris R, Hemphill MB, et al. Very-low-energy diets and morbidity: A systematic reviewof longer-term evidence. Evidence Report/Technology Assessment 76. JAMA. Stockholm, Sweden;SBU; 2005.

http://link.reuters.com/kuq24t

CPT codes covered if selection criteria are met:

Member has a body mass index** (BMI) greater than or equal to 30 kg/m²; or

This policy is supported by NHLBI Guidelines on Diagnosis and Management of Obesity.

134

Number:Â 0039Policy

Body plethysmography (diagnostic study)

Polyphagia

5'2"

182

U.S. Ann Intern Med. Accessed June 13, 2005.

5'4"

Arterburn DE, DeLaet DE, Schauer DP. 3rd ed. 103. Use and abuse of appetite-suppressant drugs inthe treatment of obesity. Gastroenterology. J Athl Train. 170. N Engl J Med. Nutrition and yourhealth: Dietary guidelines for Americans. Am J Clin Nutr. Physiol Meas. Bethesda, MD: AmericanSociety of Health-System Pharmacists; 1998.

Phentermine [Adipex-P], and

327.23

5'7"

Cushing's syndrome

148

80418

Weight management classes, non-physician provider, per session

Available evidence does not support the use of whole body DEXA for managing obesity. Comparisonof different methods to assess body composition of weight loss in obese and diabetic patients.2007;51(5):421-427.

The ReeVue Indirect Calorimeter (KORR Medical Technologies, Salt Lake City, UT) was designed tomeasure an individual's oxygen consumption. Using this measurement, the device calculates aperson's resting energy expenditure (REE), also known as resting metabolic rate (RMR). Clinicianssupposedly can screen for abnormally low metabolic rates, teach energy balance, and identify theprecise caloric intake needed for weight loss. Clinical applications of the ReeVue IndirectCalorimeter include obesity treatment, as well as treating obesity related diseases such as diabetes,dysmetabolic syndrome X, hypothyroidism, hyperthyroidism, hypertension, cardiovascular disease,as well as sleep apnea. Under strict laboratory protocol, the ReeVue can also be used to measurebasal metabolic rate.

O'Meara S, Riemsma R, Shirran L, et al. Baillieres Clin Endocrinol Metab.  Reference lists ofstudies and reviews were manually searched. Preventive Services Task Force. Everett KoopFoundation, and Shape Up America! Guidance for treatment of adult obesity. Bethesda, MD: ShapeUp America!; October 1996. Available at: http://www.shapeup.org/sua. Treatment of obesity inchildren and adolescents. Technology Assessment ReportNo.90. Bloomington,MN:ICSI;2005. Available at:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=2243. Accessed February 7, 2006.

Diabetes

82952

Â

Pineau JC, Filliard JR, Bocquet M. Systematic review: An evaluation of major commercial weight lossprograms in the United States. ;1991;368.

170

Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral insame year for change in diagnosis, medical condition or treatment regimen (including additionalhours needed for renal disease), group, (2 or more individuals), each 30 minutes

5'6"

Serum chemistries and liver function tests (SMA 20)Â weekly during the rapid weight loss phase ofthe VLCD, then every 2 weeks thereafter up to 16 weeks.

Weight reduction medications should be used as an adjunct to caloric restriction, exercise, and

behavioral modification, when these measures alone have not resulted in adequate weight loss. 19thed. 2007;298(14):1661-1673.

Note: Under most benefit plans, the following services and supplies for weight reduction arespecifically excluded from coverage (please check benefit plan descriptions for details)

Wadden TA, Berkowitz RI, Womble LG, et al. Appetite suppressants: A review. AHRQ Publication No.UpToDate Inc., Waltham, MA.

126

Nutrition classes, non-physician provider, per session

Furthermore, an UpToDate review on "Palliative care: Assessment and management of anorexia andcachexia" (Bruera and Dev, 2013) states that "Handheld indirect calorimetry, which is more accuratethan equations at estimating basal energy needs but less precise than traditional devices used in theresearch setting, may be useful in the outpatient setting. Close to one-half of cancer patients beingevaluated in an outpatient cachexia clinic are noted to be hypermetabolic by indirect calorimetry. These assessments are appropriate in the research setting, but have little if any utility in the clinic".

150

Hospital confinement is considered not medically necessary for a weight reduction program.

Whitlock EP, O'Connor EA, Williams SB, et al. Food and Drug Administration (FDA).2008;(3):CD003054.

124

For Aetna's clinical policy on surgical management of obesity, see CPB 0157 - Obesity Surgery.

163

197

80053

202

Ball SD, Altena TS. St. Â Several studies incorporated aspects of behavior therapy, exercise, low-fatdiets, low-carbohydrate diets or medication. Washington, DC: U.S. A rapid and systematic review ofthe clinical effectiveness and cost-effectiveness of orlistat in the management of obesity. Br J Nutr.2002;123(3):879-881.

S9449

132

Height

153

Institute for Clinical Systems Improvement (ICSI). 2004;(3):CD004094.

Weight reduction medications, and

118

Pittler MH, Ernst E. Evidence based review of weight loss medicines:Â A report commissioned by theNew Zealand Accident Compensation Corporation (ACC). Â Interpretation of the results, however,was restricted and conclusions with which to guide best practice were limited due to heterogeneitybetween the studies. 2006;83(5):1047-1054.

150

80048

Abell TL, Minocha A, Abidi N. Role of phytotherapy in the prevention and treatment of obesity.Cochrane Database Syst Rev. West J Med. Rockville, MD: Agency for Healthcare Research andQuality; July 2004. Â The duration of the studies ranged from 12 months to 5 years. 1992;43(6):820-836.

84550

Aetna considers the following medically necessary treatment of obesity when criteria are met:

168

Dyslipidemia:

The above policy is based on the following references:

BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

Indirect calorimetry (e.g., ReeVue Indirect Calorimeter) (diagnostic study)

**BMI = weight (kg) ¸ [height (m)]² http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm

151

Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral insame year for change in diagnosis, medical condition or treatment regimen (including additionalhours needed for renal disease), individual, face to face with patient, each 15 minutes

Weight reduction medications are considered experimental and investigational when these criteriaare not met.

Human chorionic gonadotropin (HCG) or vitamin injections for weight loss

6'1"

188

Whole body calorimetry and composition is considered experimental and investigational for weightreduction and other indications.

5'8"

Garvey et al (2012) conducted a placebo-controlled, double-blind, 52-week extension study toevaluate the long-term efficacy and safety of controlled-release phentermine/topiramate (PHEN/TPMCR) in overweight and obese subjects with cardiometabolic disease. Subjects were randomlyassigned to placebo, 7.5 mg phentermine/46 mg controlled-release topiramete, or 15 mgphentermine/92 mg controlled-release topiramate.  Of the 676 extension study participants, 84%completed the study. At week 108 PHEN/TPM-CR was associated with significant, sustainedweight loss. Significantly more PHEN/TPM CR-treated subjects at each dose achieved >= 5%, >=10%, >= 15%, and >= 20% weight loss compared with placebo (P < 0.001). The authors thereforeconcluded that PHEN/TPM CR, in conjunction with lifestyle modification, may provide a well-tolerated and effective option for the sustained treatment of obesity complicated by cardiometabolicdisease.

Weight (lbs.)

Whitlock EP, Williams SB, Gold R, et al. Ann Nutr Metab. Preventive Services Task Force SystematicEvidence Review No. 2004;25(3):671-678.

The following services are considered medically necessary for the evaluation of overweight orobese individuals:

National Institute for Health and Clinical Excellence (NICE). 2007;77(3):405-411.

278.00 - 278.02

U.S. Obesity. In: Harrison's Principles of Internal Medicine. Ann Intern Med. Effective Health Care.MM Eschleman, ed. Meta-analysis: The effect of dietary counseling for weight loss.  Periods ofVLED ranged from 25 d to 9 months. Preventive Services Task Force. Behavioral counseling inprimary care to promote a healthy diet: Recommendations and rationale. Lippincott Co.2010;70(3):335-346.

Williams JE, Wells JC, Wilson CM, et al. No. Prepared by the Oregon Evidence-based Practice Centerunder Contract No. NZHTA Report. Am J Med Sci. Part I. 2003;24(1):93-100.

HCPCS codes not covered for indications listed in the CPB:

U.S. 2006;29(4):277-302.

National Task Force on the Prevention and Treatment of Obesity, National Institutes ofHealth. Long-term pharmacotherapy in the management of obesity.JAMA. Postmarketing drugsafety information for patients and providers. Rockville, MD: Agency for Healthcare Research andQuality (AHRQ); September 2008.

137

Note: Many Aetna benefit plans specifically exclude coverage of weight reduction medications underthe pharmacy benefit and/or under the health benefits plan. 2009;44(2):142-147.

Wilfley DE, Stein RI, Saelens BE, et al. Am J Clin Nutr. London, UK: BMJ Publishing Group Ltd.; April30, 2004.

Li Z, Maglione M, Tu W, et al. Pathogenesis. Ultrasound techniques applied to body fat measurementin male and female athletes. What is the evidence for the safety and effectiveness of surgical andnon-surgical interventions for patients with morbid obesity? NZHTA Technical Brief Series.Guidance on the use of orlistat for the treatment of obesity in adults. Interventions to preventobesity: A systematic review. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ);2003.

157

+ 97814

Benzphetamine [Didrex],

U.S. Treatment of obesity. Technology Appraisal Guidance No.22. Am J Prev Med. Available athttp://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.19289. Evaluation of Lunar Prodigydual-energy X-ray absorptiometry for assessing body composition in healthy persons and patients bycomparison with the criterion 4-component model.

82951

111

Dansinger ML, Tatsioni A, Wong JB, et al. Dietary supplements for body-weight reduction: Asystematic review. Gain and loss in weight. Nowadays, medicinal plants and natural treatments arebecoming more and more popular. American Hospital Formulary Service Drug Information 98.Nutrition. Last reviewed October 2013. 2004;5(1):51-68.

5'7"

Notes: Prepackaged food supplements or substitutes and grocery items are generally excluded fromcoverage under most benefit plans. Diagnostic tests required by, for or as a result of non-coveredweight loss programs (e.g., those not requiring physician supervision) are not covered. Pleasecheck benefit plan descriptions for details.

Clinician supervision of weight reduction programs.

172

Weight Reduction Medications and Programs. 2012;61(2):262-72.

Mosby-Year Book, Inc. Ephedra and ephedrine for weight loss and athletic performanceenhancement: Clinical efficacy and side effects. Health Qual Life Outcomes. Effectiveness of weightmanagement interventions in children: A targeted systematic review for the USPSTF. Systematicreview of the long-term effects and economic consequences of treatments for obesity andimplications for health improvement. Palliative care: Assessment and management of anorexia and

cachexia. Different mechanisms for the anti-diabetic effect of plants have been proposed: increasedrelease of insulin, reduction of intestinal glucose absorption, as well as enhancement of glycogensynthesis. 1994;60(5):647-657.

121

176

Haller C, Schwartz JB. Pharmacologic agents for weight reduction. J Gend SpecifMed. 2002;5(5):16-21.

6'0"

6'3"

Â

153

Exercise classes, non-physician provider, per session

Whitlock EP, O'Connor EA, Williams SB, et al. 2006;35(8):576-579.

147

Glucose tolerance test (GTT)

G0270

Rogovik AL, Chanoine JP, Goldman RD. 290-02-0024. Looking to the future: Electrical stimulation forobesity. Am J Clin Nutr. KCE Reports 36. 1996;276:1907-1915.

5'11"

151

155

Other than orlistat (Xenical), which is approved for use in adolescents aged 12 years or older, weightreduction medications have not been proven to be safe and effective for treatment of obesity inchildren and adolescents.  Orlistat (Xenical) is contraindicated in persons with chronicmalabsorption syndromes and cholestasis. SBU Report No. Health Technol Assess. 2002;6(6):1-97.

5'0"

Lambert M-L, Kohn L, Vinck I, et al. Evidence Report/Technology Assessment No. CochraneDatabase Syst Rev. Technology Assessment Report No.87. Bloomington,MN:ICSI;January2005. Available at:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1993. Accessed February 7, 2006.

173

113

Balazs A. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA);2004;7(6).

97803

Ideal weights for adult men:

Blissmer B, Riebe D, Dye G, et al. Clinical guidelines on the identification, evaluation, and treatmentof overweight and obesity in adults. For such individuals, use of weight reduction medication mayneed to be chronic.

121

157

Ioannides-Demos et al (2006) stated that there is limited safety and effectiveness data foramfepramone (diethylpropion) and phentermine and their approvals for the management of obesityare limited to short-term use.  The authors stated that, although the benefit-risk profiles ofsibutramine and orlistat appear positive, sibutramine continues to be monitored because of long-term safety concerns. The safety and effectiveness of currently approved drug therapies have notbeen evaluated in children and elderly patient populations.

** For a simple and rapid calculation of BMI, please click below and it will take you to the ObesityEducation Initiative:

Foster DW. Orv Hetil. Department of Agriculture and U.S. Please check benefit plan descriptions fordetails.

77072

Diethylpropion [Tenuate],

6'4"

Institute for Clinical Systems Improvement (ICSI). Weight control. JAMA. Rockville, MD: Agency forHealthcare Research and Quality (AHRQ); 2003.

97810

Bjorntorp P. 2006;331(4):226-232.

145

Other and unspecified endocrine disorders

Smartt P. dual-energy X-ray absorptiometry. Safety of drug therapies used for weight loss andtreatment of obesity. What works for obesity? A summary of the research behind obesityinterventions. 1994;8(3):705-727.

The following indicates maximum ideal weight in shoes with one-inch heels based on body frame andheight:

148

Dual-energy X-ray (DEXA) was developed for the diagnosis of osteoporosis and was employedoriginally to clinically significant locations of the forearm, femoral neck, and lumbar spine. Withbody composition measurements by means of DEXA, a controlled x-ray beam scans the entirebody to ascertain bone mineral content, body fat and lean tissue mass. The comprehensive viewof body composition provided by DEXA is thought to be the method of choice for evaluating bodycomposition by its advocates because of its speed, ease of application as well as relatively low-doseof ionizing radiation. Its purported uses entail determining appropriate nutritional supportduring disease progression and monitoring response to therapeutic interventions.

V85.0 - V85.22

Bray GA. Bethesda, MD: NIH; June 1998.

Phendimetrazine [Bontril]Â

V85.23 - V85.44

5'3"

National Task Force on the Prevention and Treatment of Obesity, National Institutes ofHealth. Very low-calorie diets. 2002;137(3):205-207.

Snow V, Barry P, Fitterman N, et al. 1993;270:967-974.

Weight (lbs.)Â Â

159

151

Metabolic and chemistry profile (serum chemistries, liver tests, uric acid) (SMA 20)

American Society of Health-System Pharmacists, Inc. Department of Health and Human Services.Drug Saf. Pharmacotherapy and weight-loss supplements for treatment of paediatric obesity. 232.New York, NY: McGraw-Hill; 1998:244-246.

Pure hypercholesterolemia

Heshka S, Anderson JW, Atkinson RL, et al. Weight loss with self-help compared with a structuredcommercial program: A randomized trial. JAMA. 2003;289(14):1792-1798.

Urinalysis

172

S9451

80076

84560

HCPCS codes covered if selection criteria are met:

80420

Large Frame

5'9"

Medium Frame

143

142

115

255.0

138

Lorcaserin [Belviq],

159

163

Weight Reduction Medications:

144

Up to a combined limit of 26 individual or group visits by any recognized provider per 12-monthperiod are considered medically necessary for weight reduction counseling in adults who are obese(as defined by BMI >= 30 kg/m2**). Meta-analysis: Pharmacologic treatment of obesity. Obesity:The prevention, identification, assessment and management of overweight and obesity in adults andchildren.  These researchers investigated longer-term outcomes from studies using VLED, with aminimum duration of 12 months, published between January 2000 and December 2010. 8th ed.Meridia (sibutramine hydrochloride) information. Metabolic drugs: Drugs used in obesity. Exerciseor exercise and diet for preventing type 2 diabetes mellitus. Diet programs for weight loss inadults. Technology Assessment ReportNo.83.Bloomington,MN:ICSI;August2004.Availableat:http://www.icsi.org/knowledge/detail.asp?catID=107&itemID=1742. 2005;116(1):e125-e144.

Bra GA, Gray DS. 71. Pediatrics. 2005;353(20):2111-2120.

127

84479

O'Meara S, Riemsma R, Shirran L, et al. AHRQ Publication No.  Studies conducted in both childrenand adults, with a mean/median BMI of greater than or equal to 28 kg/m2 were included. Screeningand interventions for overweight and obesity in adults. In: USP DI: Drug Information for the HealthCare Professional. Under these plans, claims for weight reduction medications and for physiciansupervision of weight reduction programs will be denied based on that exclusion. Please checkbenefit plan descriptions for details.

139

151

Excluded Services:

Other HCPCS Codes related to the CPB:

Scheen AJ, Desaive C, Lefebvre PJ. Â A total of 32 out of 894 articles met the inclusion criteria.National Heart, Lung, and Blood Institute and National Institute of Diabetes and Digestive andKidney Diseases. The prevention and treatment of childhood obesity. Â PubMed, Medline, Web ofScience and Science Direct were searched. Validation of ultrasound techniques applied to body fatmeasurement. If weight is lost in the initial 6 months of therapy or is maintained after the initialweight loss phase, this should be considered a success and the drug may be continued.

148

Shepherd TM. Effective management of obesity. J Fam Pract. 2003;52(1):34-42.

97804

Lipid profile (total cholesterol, HDL-C, LDL-C, triglycerides)

Hand x-ray for bone age -- child

141

No author listed. Qsymia is contraindicated in pregnancy, glaucoma,hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days oftaking monoamine oxidase inhibitors. Belviq is contraindicated in pregnancy. 2012;28(6):630-634.

141

O'Meara S, Riemsma R, Shirran L, et al. 83. Pharmacologic and surgical management of obesity inprimary care: A clinical practice guideline from the American College of Physicians. Ann InternMed. Accessed March 16, 2000.

156

Asp N G, Bjorntorp P, Britton M, et al. Â Current evidence demonstrated significant weight loss andimprovements in blood pressure, waist circumference and lipid profile in the longer term following aVLED. AS Fauci, E Braunwald, KJ Isselbacher, et al., eds. London, UK: BMJ Publishing Group; July2005.

Mulholland Y, Nicokavoura E, Broom J, Rolland C. Rockville, MD: United States PharmacopeialConvention; 1999: 452-459.

Exercise programs or use of exercise equipment

5'3"

American Obesity Association, C. 08-E014. Technology Assessment Report No. Factors influencingsuccessful weight loss are: weight loss during dieting alone, adherence to diet, eating habits,motivation and personality.

CPT codes not covered for indications listed in the CPB:

Avenell A, Broom J, Brown TJ, et al. Behavioral therapy programs for weight loss in adults. Thenumber of medically necessary visits for obese children are left to the discretion of the member'sphysician.

Obstructive sleep apnea (adult) (pediatric)

84478

Hypertensive disease

Member has a BMI greater than or equal to 27 kg/m² with any of the following obesity-related riskfactors considered serious enough to warrant pharmacotherapy:

93000 - 93010

Comprehensive history and physical examination

National Institute for Clinical Excellence (NICE). Long-term pharmacotherapy for obesity andoverweight. Bloomington, MN: ICSI; March 2004.Â

414.00 - 414.9

Weight loss due to weight reduction medication use is generally temporary. 2005;142(7):532-546.

G0271

131

Other ICD-9 Codes related to the CPB:

Background

+ 97811

Small Frame

85027

97813

Bruera E, Dev R. Â The authors concluded that the present review clearly identified the need formore evidence and standardized studies to assess the longer-term benefits from weight lossachieved using VLED.

Obstructive sleep apnea

Orlistat [Xenical, Alli],

Weight reduction medications are considered medically necessary for members who have failed tolose at least one pound per week after at least 6 months on a weight loss regimen that includes a lowcalorie diet, increased physical activity, and behavioral therapy, and who meet either of thefollowing selection criteria below:

Ritz P, Sallé A, Audran M, Rohmer V. 2005:142(7):525-531.

No author listed. 160. Pediatrics. A comparison between ultrasound techniques, air displacementplethysmography and bioelectrical impedance vs. There is a lack of reliable evidence demonstratingthat whole body DEXA measurement improves the management of persons with obesity over simplermethods of measuring body composition (including BMI and anthropomorphic measures), suchthat clinical outcomes are significantly improved. Published data have focused on the level ofagreement between whole body DEXA and various other methods of measuring body composition,and on the use of DEXA as an endpoint in research studies. Well-designed studies are needed toassess the clinical value of whole body DEXA scanning (Ball and Altena, 2004; Williams et al,2006; Ritz et al, 2007; Pineau et al, 2007; Pineau et al, 2009).

134

176Â

LDL cholesterol greater than or equal to 160 mg/dL, or

5'11"

138

145

6'2"

174

154

Body mass index less than 19-26.9, adult

Triglycerides greater than or equal to 400 mg/dL

160

Appendix

Ioannides-Demos LL, Proietto J, Tonkin AM, McNeil JJ. London, UK: NICE; 2006.

Height

140

5'10"

133

5'6"

Note: VLCDs extending beyond 16 weeks are subject to medical review to determine if additionalservices are medically necessary.

Goldstein DJ, Potvin JH. 2004;8(21): iii-iv, 1-182.

5'8"

Clinical Policy Bulletin:

140

Coronary atherosclerosis

Thyroid function tests (T3, T4, TSH)

180

Balázs (2010) stated that the rapidly increasing prevalence of over-weight and diabetes mellitus is aserious global threat to healthcare. 2007;147(1):41-50.

Large Frame

Overweight and obesity

184

176

156

Coronary heart disease

160

5'5"

259.8 - 259.9

167

250.00, 250.02, 250.10, 250.12, 250.20, 250.22, 250.30, 250.32, 250.40, 250.42, 250.50, 250.52,250.60, 250.62, 250.70, 250.72, 250.80, 280.82, 250.90, 250.92

154

Mulholland et al (2012) stated that evidence from the literature supports the safe use of very-lo--energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet atarget weight loss using a standard low-fat, reduced-energy approach. 04-E028-2. Department ofHealth and Human Services, National Institutes of Health (NIH). 2003;139(11):930-932.

Dual-energy X-ray (DEXA) body composition (diagnostic study)

U.S