S9449 — Weight management classes, non-physician provider, per session
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Records supporting medical necessity when services/tests are performed (e.g., rationale for ordering dexamethasone suppression testing, indirect calorimetry only if clinically indicated and not for non-covered programs).
- Documented BMI at baseline (to establish BMI thresholds cited for each medication/device: e.g., BMI ≥30 kg/m2 or BMI ≥27 kg/m2 with weight-related comorbidity as applicable).
- Documented prior attempts at weight reduction using caloric restriction, exercise, and behavioral modification (i.e., failure to achieve adequate weight loss with lifestyle measures) prior to initiation of pharmacologic therapy (explicitly stated as an adjunct to diet/exercise/behavioral modification).
- For agents requiring comorbidity for overweight-range BMI (27–29.9), document presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia).
Key Coverage Criteria
- For Plenity specifically, covered ICD-10 diagnoses (when selection criteria are met): E66.01 – E66.9; Z68.25 – Z68.45 (BMI 25.0 – 40+, adult).
- Didrex (benzphetamine) is indicated in the management of exogenous obesity as a short term (a few weeks) adjunct in a regimen of weight reduction based on caloric restriction in patients with an initial body mass index (BMI) of 30 kg/m2 or higher who have not responded to appropriate weight reducing regimen (diet and/or exercise) alone.
- Contrave (naltrexone and bupropion) is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index (BMI) of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
- Orlistat (Xenical, Alli) is indicated for obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet. It is also indicated to reduce the risk for weight regain after prior weight loss. (Xenical available as 120 mg; Alli OTC 60 mg.)
- Qsymia (phentermine and topiramate) is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of: 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbidity such as hypertension, type 2 diabetes mellitus, or dyslipidemia.
- Liraglutide (Saxenda) is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with obesity (BMI ≥30 kg/m2) or who are overweight (BMI ≥27 kg/m2) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia).
1 Active Policy
AETNA-CPB-0039 — Weight Reduction Programs and Devices
Related Codes
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