CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Intensive Behavioral Therapy (IBT) for Obesity - Coverage Criteria

Defines coverage and correct use of time-based HCPCS Level II G codes for Intensive Behavioral Therapy for obesity for Medicare Advantage and commercial members, and describes visit frequency and documentation expectations for providers.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyIntensive Behavioral Therapy (IBT) for Obesity - Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2014

Next Review DateN/A

Key ActionReport each IBT visit using G0447 (individual) or G0473 (group) and document time-qualified counseling following the 5As approach.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥30BMI threshold for IBT eligibility

Weekly x1 moVisit frequency - first month

Every other weekVisit frequency - months 2-6

≥3 kg lossContinuation criteria for months 7-12

G0447,G0473Reportable IBT codes

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Coverage criteria and visit schedule

IBT coverage and visit schedule

Covered when ALL of the following are met

Eligibility: Beneficiary has BMI >= 30 kg/m2BMI >= 30 kg/m2

Includes Medicare Advantage Plans and Commercial Products

Provider and setting: Counseling furnished by a qualified primary care practitioner in a primary care setting

Primary care practitioners include physicians with Family Practice, General Practice, Geriatric Medicine, Internal Medicine, Obstetrics/Gynecology, Pediatric Medicine; qualified non-physician practitioners include nurse practitioners and physician assistants. Emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities and hospices are not considered primary care settings.

Service reporting: Each visit reported with G0447 (15 min individual) or G0473 (group 2-10, 30 min)

Time-based HCPCS Level II G codes used; service is considered a preventive health benefit covered without copayment/coinsurance/deductible as applicable under preventive benefits.

Visit frequency: One face-to-face visit every week for the first month; one face-to-face visit every other week for months 2-6; one face-to-face visit every month for months 7-12 only if beneficiary meets the 3 kg weight loss requirement during the first 6 monthsSee text

IBT consists of BMI screening, dietary assessment, and intensive behavioral counseling to promote sustained weight loss.

For purposes of Intensive Behavioral Therapy (IBT) coverage, services must be furnished in a primary care setting by a qualified primary care practitioner. A primary care setting is one that provides integrated, accessible care by clinicians accountable for a majority of personal health care needs and sustaining a patient partnership. The policy specifically excludes the following from being considered primary care settings: emergency departments, inpatient hospital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices.

Services that are determined to be not medically necessary or that qualify as non-covered benefits are not payable. Providers may be prohibited from billing members for such services except in circumstances where the member has been informed and provided written agreement in advance to accept financial responsibility. Refer to provider participation agreements for applicable billing restrictions and balance-billing provisions.

Codes, BMI threshold, and continuation thresholds

Covered HCPCS Level II G codesHCPCSCovered

G0447	Face-to-Face behavioral counseling for obesity, 15 minutes
G0473	Face-to-face behavioral counseling for obesity, group (2-10), 30 minutes

BMI — eligibility threshold

BMI eligibility thresholdBMI ≥ 30 kg/m2

Applies toMedicare Advantage and Commercial members as described

Beneficiary conditionPatient must be competent and alert at time counseling is provided

Weight loss requirement for months 7-12 — continuation criteria

Continuation requirement for months 7–12Beneficiary must have ≥ 3 kg weight loss during the first 6 months to receive monthly visits in months 7–12

Timing of assessmentWeight loss assessed at end of first 6 months to determine eligibility for months 7–12 visits

Provider obligations, documentation, and billing implications

Prior Authorization

Prior authorization is not required for intensive behavioral therapy (IBT) for obesity services.

Prior authorization: Not applicable

Billing Rule

Coverage and Billing Reminder

Behavioral counseling for obesity is covered when billed using the time-based HCPCS Level II G-codes for obesity-related counseling provided as time-based evaluation and management (E/M) services. When covered as a preventive health benefit under applicable plans, these services may be provided without member copayment/coinsurance and deductible per the member's preventive benefits.

Applicable plans: Medicare Advantage and Commercial products

Clinical background and policy scope

Obesity prevalence in the United States has risen substantially over recent decades; in the Medicare population more than 30% of men and women are obese, and obesity is associated with many chronic conditions including cardiovascular disease, musculoskeletal disorders, and diabetes. Medicare-defined IBT for obesity applies to adults with a BMI ≥ 30 kg/m2 and includes BMI screening, dietary (nutritional) assessment, and intensive behavioral counseling and therapy to promote sustained weight loss through high-intensity interventions addressing diet and exercise. Coverage is provided when counseling is furnished to competent, alert beneficiaries by qualified primary care practitioners (including specified physician specialties and qualified non-physician practitioners) in a primary care setting.

Key definitions and frameworks

Primary care practitioner / setting

Qualified physician specialtiesFamily Practice, General Practice, Geriatric Medicine, Internal Medicine, Obstetrics/Gynecology, Pediatric Medicine

Qualified non-physician practitionersNurse practitioners and physician assistants

Primary care setting exclusionsEmergency departments, inpatient hospitals, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehab facilities, and hospices are not considered primary care settings

5As — IBT session framework

5As frameworkAssess, Advise, Agree, Assist, Arrange — framework for each IBT session

AssessAsk about or assess behavioral health risks and factors affecting behavior change goals or methods