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Demonstration projects and legislation also affected reimbursement of weight loss programs. The Medicare Lifestyle Modification Program Demonstration tested the effectiveness of program services for Medicare beneficiaries with moderate to severe coronary artery disease. The demonstration included two multiple-site, 12-month, multidisciplinary, clinical outpatient treatment programs. Participants in Dr. Ornish’s program for reversing heart disease, with a proposed enrollment of 1,800 patients, were reimbursed 80% of the program fee of $5,650, and the beneficiary portion of the program fee (20%) could be waived. [98]

Additionally, Medicare initiated coverage of medical nutrition therapy when furnished by a registered dietitian for beneficiaries with diabetes or chronic kidney disease. Reimbursement required a physician referral. Coverage included three hours of counseling in the first year and two hours thereafter and was reimbursed at approximately $75 per hour. [99]

Commercial coverage Coverage of weight loss and lifestyle modification varied by commercial insurer. The policies of Blue Cross Blue Shield Massachusetts (BCBSMA), Massachusetts’s largest commercial health insurance provider, [100] are described below.

Alternative health care benefits—Members were eligible for 20% discounts to Weight Watchers and sessions with registered dietitians (no physician referral needed). [101] The 20% discounts were absorbed by those providers (no payment received from insurer) who wanted to be listed as part of BCBSMA’s alternative care network.

Nutritional and/or weight loss counseling—Nutritional and/or weight loss counseling by a physician, physician assistant, nurse practitioner, or registered dietitian (requires physician referral and authorization for three visits, additional visits require another authorization) would be covered as follows: Obesity and overweight—maybe; Prediabetes—probably; High blood pressure, high cholesterol, and diabetes—yes, but limited in time and duration.

The cost to patients of nutritional counseling for a covered illness generally approximated $10 to $20 per visit. [102]

Intensive lifestyle modification—Exercise and education programs, risk factor modification (e.g., dietary, stress reduction, smoking cessation), and counseling were covered under BCBSMA’s cardiac rehabilitation policy. The total number of visits covered varied between 8 and 24. To be covered, the program must be initiated 26 weeks after an acute myocardial infraction, cardiovascular surgery, or a coronary angioplasty (heart procedures or surgeries). [103]

Pharmaceutical therapy—Weight loss drug therapy was covered for overweight patients with a BMI over 27 and comorbid conditions, or obese members. Patients were given an authorization for three months of Orlistat. [104] Additional authorizations required documentation of weight loss of at least four pounds per month.

Surgical treatment—Members were covered when the following conditions were met: morbid obesity; repeated failed attempts at weight loss; obesity had persisted for five or more years; no untreated metabolic cause for obesity; and patient is an adult. [105] Costs of the procedure to the health plan ranged from $15,000-$35,000. [106] Patients paid the applicable benefit co-pays and/or coinsurance.

One health plan medical director noted the reasons that surgery was covered and counseling was not were the U.S. government’s identification of the “medical necessity” of morbid obesity surgery and various clinical studies of its effectiveness. In contrast, most people on diets regain the weight they lose. Nevertheless, reimbursement of nutritional counseling (including weight loss) for people with chronic illnesses (high blood pressure, high cholesterol, diabetes) was increasingly accepted. [107] Another factor in commercial insurance coverage of weight loss and/or lifestyle modification was member satisfaction; experts calculated a 28% average annual member disenrollment rate for health plans. [108]

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