Obesity is an increase in body weight beyond the limitation of skeletal and physical requirements, as a result of excessive accumulation of fat in the body. In general, 20% to 30% above "ideal" bodyweight, according to standard life insurance tables, constitutes obesity. Morbid obesity is further defined as a condition of consistent and uncontrollable weight gain that is characterized by a weight which is at least 100 lbs. or 100% over ideal weight or a body mass index (BMI) of 35 or greater.

Body mass index (BMI) is a method used to quantitatively evaluate body fat by reflecting the presence of excess adipose tissue. BMI is calculated by dividing measured bodyweight in kilograms by the patient's height in meters squared. The normal BMI is 20-25 kg/meters squared.

Medical Treatment
Obesity itself is not considered an illness or disease. Services performed solely for the diagnosis or treatment of this condition are non-covered.

Any weight-reduction services performed in the treatment of concomitant medical conditions (e.g., hypertension), even when those medical conditions could be improved through weight loss, are also non-covered.

Surgical Treatment
Gastric stapling, "vertical banded gastroplasty", and gastric bypass surgery reported for the treatment of "Morbid Obesity" are eligible. Claims for laparoscopic Roux-en-Y gastric bypass should be reported under code 43659. (See MPB S-96 for additional information on laparoscopic surgery.)

In addition, itemized charges reported for gastroduodenostomy and/or gastrojejunostomy in conjunction with gastric stapling or gastric bypass surgery should be combined with the stapling or bypass surgery.

Refer to Medical Policy Bulletin G-21 (procedures of questionable current usefulness) for intestinal bypass surgery.

Comprehensive and Wraparound

Payment should not be made for medical services performed for the evaluation and treatment of obesity alone unless such services are a necessary treatment of a disease or condition aggravated by obesity (e.g., cardiac and respiratory diseases, diabetes, and hypertension).

PRN References

02/1993, Obesity