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HealthPartners

Coverage criteria policies

Weight loss management

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for weight loss management. Please see related content at the right for link to the Dietitian Consultation policy.

Prior authorization is required for Weight Loss Surgery. Please see related content at the right for link to the Weight Loss Surgery policy.

Coverage

A member's medical coverage is limited to certain physician-supervised medical weight loss or medical management treatments that have been scientifically proven.

Indications that are covered

  1. Physician-directed dietary consultation services are covered when the medical criteria that are listed in the Dietitian Consultation Policy have been fulfilled. Please see related content for at the right for link to policy.
  2. Surgical weight loss services are covered when:
    1. The surgeon is a member of the Designated Provider Network for Weight Loss Surgery; and
    2. The medical criteria listed in the Weight Loss Surgery Policy have been fulfilled. Please see related content for at the right for link to policy.

Indications that are not covered

In addition to those interventions that are covered under your policy, there are other interventions or lifestyle activities that you may wish to pursue or may be recommended by a physician or health care professional that are not covered. Examples of these activities include, but are not limited to:

  1. Health club memberships, exercise programs, use of exercise equipment or purchase of exercise equipment.
  2. Physical performance testing and measurement, including, but not limited to: pulmonary stress testing to determine exercise capacity as a routine component of an exercise program.
  3. Lifestyle-behavioral resources or equipment (i.e. biofeedback, support groups).
  4. Support programs such as Weight Watchers, Jenny Craig, Diet Center, Zone Diet or other similar programs.
  5. Nutritional supplements and foods, including but not limited to vitamins, amino acid supplements, Optifast, Medifast, prepackaged meals such as NutriSystem or phytotherapy.
  6. Acupuncture
  7. Inpatient or day treatment programs for weight loss.

Definitions

Weight loss management is a lifelong process of balanced eating, physical activity and lifestyle change. These strategies have proven successful in achieving or maintaining a healthy body weight, improved health and decreased risk for disease. Weight loss management also may include dietitian consultation. In certain circumstances, weight loss surgery may be considered. Even after surgery, lifelong medical surveillance and a weight maintenance program of balanced eating, physical activity and lifestyle change are necessary.

Body Mass Index (BMI) is measure of body fat based on height and weight that applies to both adult men and women. Please see related content at the right for a link to calculate your BMI.

In order to determine if weight loss management is necessary, physicians may use the following measures to determine if an individual is overweight or obese. These measures follow the National Heart, Lung and Blood Institute's (NHLBI) clinical guidelines for identifying and treating overweight and obesity in adults.

  • Individual's body mass index (BMI) is 25-29.9 (Class I), 30-40 (Class II) or greater than 40 (Class III).
  • Women with a BMI of 25 to 34.9 and a waistline greater than 35 inches.
  • Men with a BMI of 25-34.9 and a waistline greater than 40 inches.
  • Co-existing health conditions including high blood pressure, high cholesterol, diabetes and/or obstructive sleep apnea are present.

Weight loss management programs that include a low-calorie and low-fat diet, regular physical activity, as well as education and support to make lifestyle changes are typically the first option for overweight and obese adults. Although these programs are important to maintaining good health, payment for these programs is not reimbursed under your policy.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 800-233-9645.

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Policy activity

  • 01/01/1994 - Date of origin
  • 10/23/2018 - Effective date
Review date
  • 10/2018
Revision date
  • 10/08/2018

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