Clinical Policy Bulletin: Weight Reduction Medications and Programs
Note: Many Aetna plan benefit descriptions specifically exclude services and supplies for or related to treatment of obesity or for diet and weight control. Under these plans, claims for weight reduction medications and for physician supervision of weight reduction programs will be denied based on that exclusion. Please check benefit plan descriptions for details.
Aetna considers the following medically necessary treatment of obesity when criteria are met:
Weight reduction medications, and
Clinician supervision of weight reduction programs.
Weight Reduction Medications:
Note: Many Aetna benefit plans specifically exclude coverage of weight reduction medications under the pharmacy benefit and/or under the health benefits plan. The medical necessity criteria set forth below do not apply to health plans that specifically exclude services and supplies for or related to treatment of obesity or for diet or weight control. Under these plans, claims for weight loss drugs will be denied based on this exclusion. For members whose medical policies do not exclude weight reduction medications or services and supplies for or related to weight reduction programs, Aetna covers these drugs under the medical benefit, not the pharmacy benefit. Please check benefit plan descriptions for details.
Weight reduction medications are considered medically necessary for members who have failed to lose at least one pound per week after at least 6 months on a weight loss regimen that includes a low calorie diet, increased physical activity, and behavioral therapy, and who meet either of the following selection criteria below:
Member has a body mass index** (BMI) greater than or equal to 30 kg/m²; 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 pharmacotherapy:
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.
Weight reduction medications are considered experimental and investigational when these criteria are not met.
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:
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)
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.
This policy is supported by NHLBI Guidelines on Diagnosis and Management of Obesity.
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. Factors influencing successful weight loss are: weight loss during dieting alone, adherence to diet, eating habits, motivation and personality.
Weight loss due to weight reduction medication use is generally temporary. In addition, the potential for development of physical dependence and addiction is high. 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.
Individuals who cannot maintain weight loss through behavioral weight loss therapy and are at risk of medical complications of obesity are an exception to this; for these persons, the risk of physical dependence or other adverse effects may present less of a risk than continued obesity. For such individuals, use of weight reduction medication may need to be chronic.
Tests with weight loss drugs have shown that initial responders tend to continue to respond, while initial non-responders are less likely to respond even with an increase in dosage. If a person does not lose 2 kg (4.4 lb) in the first four weeks after initiating therapy, the likelihood of long-term response is very low. If weight is lost in the initial 6 months of therapy or is maintained after the initial weight loss phase, this should be considered a success and the drug may be continued.
Other than orlistat (Xenical), which is approved for use in adolescents aged 12 years or older, weight reduction medications have not been proven to be safe and effective for treatment of obesity in children and adolescents. Orlistat (Xenical) is contraindicated in persons with chronic malabsorption syndromes and cholestasis. Qsymia is contraindicated in pregnancy, glaucoma, hyperthyroidism, hypersensitivity to sympathomimetic amines, and within 14 days of taking monoamine oxidase inhibitors. Belviq is contraindicated in pregnancy. Other drugs listed in this policy are contraindicated in the following conditions: hypertension, atherosclerosis, coronary artery disease, and stroke.
Ioannides-Demos et al (2006) stated that there is limited safety and effectiveness data for amfepramone (diethylpropion) and phentermine and their approvals for the management of obesity are limited to short-term use. The authors stated that, although the benefit-risk profiles of sibutramine 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 not been evaluated in children and elderly patient populations.
On October 8, 2010, Abbott Laboratories announced that that it was withdrawing its diet drug Meridia (sibutramine) from the United States, Australian and Canadian markets as a consequence of heightened concerns that the medication can trigger heart attack or stroke, especially in patients with underlying cardiovascular disease.
Dual-energy X-ray (DEXA) was developed for the diagnosis of osteoporosis and was employed originally to clinically significant locations of the forearm, femoral neck, and lumbar spine. With body composition measurements by means of DEXA, a controlled x-ray beam scans the entire body to ascertain bone mineral content, body fat and lean tissue mass. The comprehensive view of body composition provided by DEXA is thought to be the method of choice for evaluating body composition by its advocates because of its speed, ease of application as well as relatively low-dose of ionizing radiation. Its purported uses entail determining appropriate nutritional support during disease progression and monitoring response to therapeutic interventions.
Available evidence does not support the use of whole body DEXA for managing obesity. There is a lack of reliable evidence demonstrating that whole body DEXA measurement improves the management of persons with obesity over simpler methods of measuring body composition (including BMI and anthropomorphic measures), such that clinical outcomes are significantly improved. Published data have focused on the level of agreement 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 to assess 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).
Balázs (2010) stated that the rapidly increasing prevalence of over-weight and diabetes mellitus is a serious global threat to healthcare. Nowadays, medicinal plants and natural treatments are becoming more and more popular. Diabetes has historically been treated with plants or plant-derived formulations in different cultures, mainly in China, Asia and India. Different mechanisms for the anti-diabetic effect of plants have been proposed: increased release of insulin, reduction of intestinal glucose absorption, as well as enhancement of glycogen synthesis. The scientific evidences for most of these plants are still incomplete. The large market for plant remedies has resulted in an array of unauthorized products or marketed as dietary supplements and, at the same time, no reliable pharmaceutical-grade products are registered for this purpose.
Borel et al (2012) conducted a prospective intervention study in 104 viscerally obese men classified according 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 insulin sensitivity was tracked. The goals of the study were to evaluate glucose tolerance as well as to evaluate the respective contribution so fo changes in body fat distribution versus changes in cardiorespiratory fitness (CRF) to the improvements in indices of plasma glucose/insulin homeostasis. The results showed insulin sensitivity improved in assocication with decreases inboth visceral (VAT) and subcutaneous adiposity (SAT) as well as improvement in CRF, regardless of baseline glucose tolerance. The results of this study also shoed that reduction in VAT was associated with an improvement in homeostasis model assessment of insulin resistance, whereas reduction in SAT was rather associated with improvement of the insulin sensitivity index of Matsuda. The authors concluded that a one year lifestyle intervention improved plasma glucose/insulin homeostasis in viscerally obese men, including those with normal glucose tolerance status at baseline.
Garvey et al (2012) conducted a placebo-controlled, double-blind, 52-week extension study to evaluate the long-term efficacy and safety of controlled-release phentermine/topiramate (PHEN/TPM CR) in overweight and obese subjects with cardiometabolic disease. Subjects were randomly assigned to placebo, 7.5 mg phentermine/46 mg controlled-release topiramete, or 15 mg phentermine/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, sustained weight 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 therefore concluded 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 cardiometabolic disease.
Mulholland et al (2012) stated that evidence from the literature supports the safe use of very-low-energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet a target weight loss using a standard low-fat, reduced-energy approach. There is, however, a need for longer-term outcomes on obesity and associated morbidities following a VLED. These researchers investigated longer-term outcomes from studies using VLED, with a minimum duration of 12 months, published between January 2000 and December 2010. Studies conducted in both children and adults, with a mean/median BMI of greater than or equal to 28 kg/m2 were included. PubMed, Medline, Web of Science and Science Direct were searched. Reference lists of studies and reviews were manually searched. Weight loss or prevention of weight gain and morbidities were the main outcomes assessed. A total of 32 out of 894 articles met the inclusion criteria. The duration of the studies ranged from 12 months to 5 years. Periods of VLED ranged from 25 d to 9 months. Several studies incorporated aspects of behavior therapy, exercise, low-fat diets, low-carbohydrate diets or medication. Current evidence demonstrated significant weight loss and improvements in blood pressure, waist circumference and lipid profile in the longer term following a VLED. Interpretation of the results, however, was restricted and conclusions with which to guide best practice were limited due to heterogeneity between the studies. The authors concluded that the present review clearly identified the need for more evidence and standardized studies to assess the longer-term benefits from weight loss achieved using VLED.
The ReeVue Indirect Calorimeter (KORR Medical Technologies, Salt Lake City, UT) was designed to measure an individual’s oxygen consumption. Using this measurement, the device calculates a person’s resting energy expenditure (REE), also known as resting metabolic rate (RMR). Clinicians supposedly can screen for abnormally low metabolic rates, teach energy balance, and identify the precise caloric intake needed for weight loss. Clinical applications of the ReeVue Indirect Calorimeter 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 measure basal metabolic rate.
Fioravante et al (2012) evaluated nutritional status, body composition, and (REE in patients with chronic hepatitis C before and during treatment with pegylated interferon and ribavirin. This was a prospective study with the evaluation of patients with hepatitis C virus before and after 12 weeks of treatment with pegylated interferon and ribavirin. The evaluation consisted of anthropometry (weight, height, BMI, and waist circumference), and body composition was determined by bioelectrical impedance analysis. The REE of each individual was obtained by indirect calorimetry. To compare the 2 phases of treatment, the Wilcoxon test was used. The significance level was 5 %. Subjects had significant weight loss during treatment with a consequent decrease in BMI. This weight decrease was accompanied by a significant decrease in body fat and no decrease 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. The authors concluded that patients with hepatitis C treatment had significant weight loss and this was not associated with changes in energy expenditure.
Furthermore, an UpToDate review on “Palliative care: Assessment and management of anorexia and cachexia” (Bruera and Dev, 2013) states that “Handheld indirect calorimetry, which is more accurate than equations at estimating basal energy needs but less precise than traditional devices used in the research setting, may be useful in the outpatient setting. Close to one-half of cancer patients being evaluated 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”.
Ideal Weight Chart:
The following indicates maximum ideal weight in shoes with one-inch heels based on body frame and height:
Ideal weights for adultmen:
Ideal weights for adult women:
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
CPT codes not covered for indications listed in the CPB:
Other CPT codes related to the CPB:
93000 - 93010
HCPCS codes covered if selection criteria are met:
Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with patient, each 15 minutes
Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), group, (2 or more individuals), each 30 minutes
HCPCS codes not covered for indications listed in the CPB:
Weight management classes, non-physician provider, per session
Other HCPCS Codes related to the CPB:
Exercise classes, non-physician provider, per session
Nutrition classes, non-physician provider, per session
ICD-9 codes covered if selection criteria are met:
The above policy is based on the following references:
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O'Meara S, Riemsma R, Shirran L, et al. A systematic review of the clinical effectiveness of orlistat used for the management of obesity. Obes Rev. 2004;5(1):51-68.
Padwal R, Li SK, Lau DC. Long-term pharmacotherapy for obesity and overweight. Cochrane Database Syst Rev. 2004;(3):CD004094.
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Ioannides-Demos LL, Proietto J, Tonkin AM, McNeil JJ. Safety of drug therapies used for weight loss and treatment of obesity. Drug Saf. 2006;29(4):277-302.
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Blissmer B, Riebe D, Dye G, et al. Health-related quality of life following a clinical weight loss intervention among overweight and obese adults: Intervention and 24 month follow-up effects. Health Qual Life Outcomes. 2006;4:43.
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National Institute for Health and Clinical Excellence (NICE). Obesity: The prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guideline 43. London, UK: NICE; 2006.
Lambert M-L, Kohn L, Vinck I, et al. Pharmacological and surgical treatment of obesity. Residential care for severely obese children in Belgium. KCE Reports 36. Brussels, Belgium: Belgian Health Care Knowledge Centre (KCE); 2006.
Dansinger ML, Tatsioni A, Wong JB, et al. Meta-analysis: The effect of dietary counseling for weight loss. Ann Intern Med. 2007;147(1):41-50.
Wilfley DE, Stein RI, Saelens BE, et al. Efficacy of maintenance treatment approaches for childhood overweight: A randomized controlled trial. JAMA. 2007;298(14):1661-1673.
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Ball SD, Altena TS. Comparison of the BOD POD and dual energy x-ray absorptiometry in men. Physiol Meas. 2004;25(3):671-678.
Williams JE, Wells JC, Wilson CM, et al. Evaluation of Lunar Prodigy dual-energy X-ray absorptiometry for assessing body composition in healthy persons and patients by comparison with the criterion 4-component model. Am J Clin Nutr. 2006;83(5):1047-1054.
Ritz P, Sallé A, Audran M, Rohmer V. Comparison of different methods to assess body composition of weight loss in obese and diabetic patients. Diabetes Res Clin Pract. 2007;77(3):405-411.
Pineau JC, Guihard-Costa AM, Bocquet M. Validation of ultrasound techniques applied to body fat measurement. A comparison between ultrasound techniques, air displacement plethysmography and bioelectrical impedance vs. dual-energy X-ray absorptiometry. Ann Nutr Metab. 2007;51(5):421-427.
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U.S. Food and Drug Administration (FDA). Meridia (sibutramine hydrochloride) information. Postmarketing drug safety information for patients and providers. Rockville, MD: FDA; updated October 8, 2010.
Rogovik AL, Chanoine JP, Goldman RD. Pharmacotherapy and weight-loss supplements for treatment of paediatric obesity. Drugs. 2010;70(3):335-346.
Whitlock EP, O'Connor EA, Williams SB, et al. Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics. 2010;125(2):e396-e418.
Balazs A. Role of phytotherapy in the prevention and treatment of obesity. Orv Hetil. 2010;151(19):763-773.
Borel AL, Nazare JA, Smith J, et al. Improvement in insulin sensitivity following a 1-year lifestyle intervention program in viscerally obese men: Contribution of abdominal adiposity. Metabolism. 2012;61(2):262-72.
Garvey WT, Ryan DH, Look M, et al. Two-year sustained weight loss and metabolic benefits with controlled-release phentermine/topiramate in obese and overweight adults (SEQUEL): A randomized, placebo-controlled, phase 3 extension study. Am J Clin Nutr. 2012;95(2):297-308.
Mulholland Y, Nicokavoura E, Broom J, Rolland C. Very-low-energy diets and morbidity: A systematic review of longer-term evidence. Br J Nutr. 2012;108(5):832-851.
Fioravante M, Alegre SM, Marin DM, et al. Weight loss and resting energy expenditure in patients with chronic hepatitis C before and during standard treatment. Nutrition. 2012;28(6):630-634.
Bruera E, Dev R. Palliative care: Assessment and management of anorexia and cachexia. Last reviewed October 2013. UpToDate Inc., Waltham, MA.
Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.