UCLA Medical Group Medical Management Guidelines

Primary Care Physician Responsibility

For the following diagnoses, in the majority of cases, the Primary Care Physician should perform the history and physical and initiate treatment. Only if the diagnosis is unclear or if patient does not respond to treatment as expected, should a referral be submitted for an initial consultation with the Dermatologist. After the Dermatologist has evaluated and diagnosed the patient, he/she will determine the need to continue treatment under his/her care or refer the patient back to the PCP to continue the recommended treatment plan. 

Photo Dynamic Therapy may be used for treatment of: Actinic Keratosis’ that are too extensive for, inappropriate for, and/or have failed cryotherapy or topical treatment with creams such as fluorouracil and imiquimod. 

This list covers the more common conditions, but there may be other dermatologic conditions that PCPs can and should treat:

• Acne Rosacea (L71.9)
• Acne Vulgaris (L70.0)
• Actinic Keratosis (L57.0) (consider referral if there is a suspicion of malignancy)
• Alopecia Areata (L63.9) (Note: PCP or Dermatologist may perform intralesional injections if covered benefit.)
• Alopecia, unspecified (L65.9)
• Cellulitis & Erysipelas (L03.90, A46)
• Dermatitis, Contact (L25.9)
• Dermatitis, Atopic Eczematous (L30.9)
• Dermatitis, Perioral (L71.0)
• Dermatitis, Seborrheic (L21.9)
• Dermatophytosis (B35.9)
• Erysipelas (A46)
• Herpes Simplex (Type I & II), Mucocutaneous (B00.9, B37.2)
• Herpes Zoster (B02.9)
• Impetigo (L01.00, L01)
• Keloid scar (L91.01)
• Melasma (L81.1)
• Molluscum Contagiosum (B08.1)
• Onychomycosis (B35.1)
• Pediculosis (B85.2)
• Psoriasis (L40.9) (consider referral if resistant or pustular)
• Pityriasis Rosea (L42)
• Scabies (B86)
• Cysts, Sebaceous & Epidermal (L72.3, L72.0) (no treatment needed unless irritating or recurrently infected)
• Seborrheic Keratosis (L82.1) (consider referral if there is a suspicion for melanoma.)
• Skin Tags, Non-Cosmetic (L91.8)
• Tinea (B35.9)
• Tinea Versicolor (B36.0)
• Verucca Vulgaris (B07.9)
• Warts (B07.9)

Cosmetic/Non-covered Conditions

Patients commonly request removal of skin lesions that are presumed by the physician to be benign. Patients referred for removal of such benign lesions, which do not meet established preauthorization criteria, need to understand that they will be financially responsible for removal of these lesions on a cosmetic / non-covered and/or medically unnecessary basis. Both the primary care physician and the dermatologist share the responsibility of informing the patient in this regard and documenting the discussion in the patient’s chart.

_{Clinical practice guidelines made available by UCLA Medical Group and Santa Monica Bay Physicians Medical Group are informational in nature and are intended as a resource for making coverage decisions for Health Plan members.  They are not a substitute for the professional medical judgment of treating physicians and it does not replace and individualized case-by-case review and medical necessity determination.  These guidelines are based on information available at the time and may not be updated with the most current information available at subsequent times. Specific care and treatment may vary depending on individual need and the benefits covered under the individuals Health Plan Contract. Disclosure of clinical practice guidelines is not a guarantee of coverage.}

Purpose

Provide an evidence based clinical policy for pharmacologic treatment of osteoporosis.

Background

Osteoporosis is a condition defined by low bone mineral density or “brittle” bones which makes patients more susceptible to fractures.

Pharmacologic treatment of osteoporosis is indicated when there is evidence of bone fragility based on low trauma fractures and/or low bone mineral density (BMD) measurements, typically in post-menopausal women and men over 50 with certain clinical findings.

(See UCLA clinical guideline on BMD testing indications)

Bisphosphanates (oral and IV) and Denosumab (IV only) work by inhibiting osteoclastic bone resorption. Anabolic Medications (Romosozumab Abaloparatide Teriparatide) work by increasing bone growth.   The choice of medication used to treat osteoporosis is determined by individual patient characteristics, severity of disease, treatment history, and the feasibility of specific treatments.

Policy

Oral Bisphosphanate treatment (such as Alendronate, ibandronate, risendronate) is the most appropriate first line initial therapy for most patients requiring pharmacologic treatment of osteoporosis with no history of fractures.

IV Bisphophanate such as Zolendronic acid is appropriate for patients with a contraindication or intolerance to oral bisphosphonates.

Denosumab is a second line treatment for patients who have completed a 3 year course of bisphosphonates or for patients with a bisphosphonate contraindication such as long-term glucocorticoid steroid use or CKD with GFR below 30-35.

Anabolic medication treatment for osteoporosis is appropriate as the initial medication treatment for certain patients with a very high fracture risk. It may also be the preferred agent in patients who have previously been on antiresorptive medication but sustained a new fracture or still have osteoporosis range BMD (after at least 2 years of anti-resorptive therapy).

• Romosozumab has the most evidence based support and is the most convenient medication with once monthly injection in the clinic setting but should not be used if the patient has had an acute myocardial infarction or thromboembolic stroke in the past 12 months.
• Teriparatide is generally considered to be equally effective and is not contraindicated in the setting of AMI or stroke. Treatment is less convenient, requires refrigeration, and consists of self-administered daily injections for 2 years.
• Abaloparatide also requires refrigeration, but only before the pen is open after which it may remain at room temperature.  Treatment consists of self-injection daily for 18 months.

It is the position of UCLA Health that the following “Very High Risk” patients (as defined below) with osteoporosis should be treated with an anabolic medication, including for initial treatment:

1. Osteoporosis range bone density (T score of -2.5 or lower) AND history of low trauma spine or hip fracture OR
2. Multiple low trauma spinal fractures or a low trauma spine or hip fracture within the last year OR
3. This form of treatment may also be indicated as first line for patients with a T score of less than -3 with significant comorbidities that increase the risk of trauma and/or have association with decreased bone strength.

References

Camacho PM, Petak S, et al. American Association of Clinical Endocrinologists / American College of Endocrinology Clinical Practice Guidelines for the diagnosis and treatment of postmenopausal Osteoporosis. Endocrine Practice Vol 26 (Suppl 1) May 2020

1. Saag K, Petersen J et al.  Romosozumab or Alendronate for fracture prevention in women with Osteoporosis.  N Engl J Med 2017; 377: 1417-27.
2. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet 2002;359:1761-7.
3. Kanis JA, Hans D, Cooper C, et al. Interpretation and use of FRAX in clinical practice. Osteoporosis Int 2011;22:2395-411.
4. McClung MR, Grauer A, Boonen S, et al. Romosozumab in postmenopausal women with low bone mineral density. N Engl J Med 2014;370:412-20.
5. Padhi D, Jang G, Stouch B, Fang L, Posvar E. Single-dose, placebo-controlled, randomized study of AMG 785, a sclerostin monoclonal antibody. J Bone Miner Res 2011;26:19-26.
6. Cosman F, Crittenden DB, Adachi JD, et al. Romosozumab treatment in postmenopausal women with osteoporosis. N Engl J Med 2016;375:1532-43.
7. Black DM, Delmas PD, Eastell R, et al. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med 2007;356:1809-22.
8. Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001;344:1434-41.
9. Reginster J, Minne HW, Sorensen OH, et al. Randomized trial of the effects of risedronate on vertebral fractures in women with established postmenopausal osteoporosis. Osteoporosis Int 2000;11:83-91.
10. Cummings SR, San Martin J, McClung MR, et al. Denosumab for prevention of fractures in postmenopausal women with osteoporosis. N Engl J Med 2009;361:756- 65.
11. Black DM, Cummings SR, Karpf DB, et al. Randomized trial of effect of alen- dronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348:1535-41.
12. Kendler D. Effects of 24 months treatment of teriparatide compared with risedronate on new fractures in postmenopausal women with severe osteoporosis: a randomized, double-dummy clinical trial (VERO trial). Presented at the World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases, Florence, Italy, March 23–26, 2017.
13. Hochberg Y. A sharper Bonferroni procedure for multiple tests of significance. Biometrika 1988;75:800-2.
14. Cranney A, Wells G, Willan A, et al. Meta-analyses of therapies for postmenopausal osteoporosis. II. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev 2002;23: 508-16.
15. Papapoulos SE, Quandt SA, Liberman UA, Hochberg MC, Thompson DE. Meta- analysis of the efficacy of alendronate for the prevention of hip fractures in postmenopausal women. Osteoporosis Int 2005; 16:468-74.
16. Keaveny TM, Crittenden DB, Bolog- nese MA, et al. Greater gains in spine and hip strength for romosozumab compared with teriparatide in postmenopausal women with low bone mass. J Bone Miner Res 2017;32:1956-62.
17. Brunkow ME, Gardner JC, Van Ness J, et al. Bone dysplasia sclerosteosis results from loss of the SOST gene product, a novel cystine knotcontaining protein. Am J Hum Genet 2001;68:577-89.
18. Chouinard L, Felx M, Mellal N, et al. Carcinogenicity risk assessment of romosozumab: a review of scientific weight-of-evidence and findings in a rat lifetime pharmacology study. Regul Toxicol Pharmacol 2016;81:212-22.
19. Didangelos A, Yin X, Mandal K, Bau- mert M, Jahangiri M, Mayr M. Proteomics characterization of extracellular space components in the human aorta. Mol Cell Proteomics 2010;9:2048-62.
20. Brandenburg VM, Kramann R, Koos R, et al. Relationship between sclerostin and cardiovascular calcification in hemodialysis patients: a cross-sectional study. BMC Nephrol 2013;4219.
21. Kramann R, Kunter U, Brandenburg VM, et al. Osteogenesis of heterotopically transplanted mesenchymal stromal cells in rat models of chronic kidney disease. J Bone Miner Res 2013;28:2523-34.
22. Rukov JL, Gravesen E, Mace ML, et al. Effect of chronic uremia on the transcriptional profile of the calcified aorta analyzed by RNA sequencing. Am J Physiol Renal Physiol 2016;310:F477-F491. 24. 25. 26.
23. Zhu D, Mackenzie NC, Millán JL, Far- quharson C, MacRae VE. The appearance and modulation of osteocyte marker expression during calcification of vascular smooth muscle cells. PLoS One 2011;6(5): e19595.
24. Claes KJ, Viaene L, Heye S, Meijers B, d’Haese P, Evenepoel P. Sclerostin: another vascular calcification inhibitor? J Clin Endocrinol Metab 2013;98:3221-8.
25. Ominsky MS, Boyd SK, Varela A, et al. Romosozumab improves bone mass and strength while maintaining bone quality in ovariectomized cynomolgus monkeys. J Bone Miner Res 2017;32:788-801.
26. Hamersma H, Gardner J, Beighton P. The natural history of sclerosteosis. Clin Genet 2003;63:192-7.
27. Li X, Ominsky MS, Niu QT, et al. Targeted deletion of the sclerostin gene in mice results in increased bone formation and bone strength. J Bone Miner Res 2008; 23:860-9.
28. van Buchem F, Prick J, Jaspar H. Hyperostosis corticalis generalisata familiaris (van Buchem’s disease). In: Excerpta medica. New York: Elsevier, 1976:1-205.
29. Vanhoenacker FM, Balemans W, Tan GJ, et al. Van Buchem disease: lifetime evolution of radioclinical features. Skeletal Radiol 2003;32:708-18.
30. Kang JH, Keller JJ, Lin HC. Bisphosphonates reduced the risk of acute myocardial infarction: a 2-year follow-up study. Osteoporos Int 2013;24:271-7.
31. Kim DH, Rogers JR, Fulchino LA, Kim CA, Solomon DH, Kim SC. Bisphosphonates and risk of cardiovascular events: a meta-analysis. PLoS One 2015;10(4): e0122646.
32. Kranenburg G, Bartstra JW, Weijmans M, et al. Bisphosphonates for cardiovascular risk reduction: a systematic review and meta-analysis. Atherosclerosis 2016; 52:106-15.
33. Lu PY, Hsieh CF, Tsai YW, Huang WF. Alendronate and raloxifene use related to cardiovascular diseases: differentiation by different dosing regimens of alendronate. Clin Ther 2011;33:1173-9. 

_{Clinical practice guidelines made available by UCLA Medical Group are informational in nature and are intended as a resource for patient care. They are not a substitute for the professional medical judgment of treating physicians.} 

Purpose

Establish an evidence based clinical policy for pain alleviating procedures in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers.

General Consultations

Initial referral to a specialist for the purpose of pain relief is appropriate after a reasonable period of standard conservative treatment fails to achieve adequate pain relief.

Spine and Paraspinal Procedures

Nerve Block with local anesthetic is medically necessary after a standard evaluation under the following conditions: 

• An examination has localized and/or reproduced pain consistent with the nerve to be anesthetized.
• Medical conditions for which this treatment would be harmful or contraindicated have been appropriately ruled out.
• The primary purpose of this injection is diagnostic, not analgesic, and should not exceed two per year.

Intra-articular facet steroid injection is a therapeutic procedure subject to the following conditions: 

• Treatment should not occur more frequently than every three months.
• Significant and lasting pain relief has been demonstrated from prior injections to the site.

Nerve destruction (chemical or other ablation) is considered medically necessary in the following circumstances: 

• Two diagnostic blocks on separate days have achieved significant pain relief.
• There has not been a prior nerve destruction within the last six months.
• Repeat procedures may be performed up to every six months without additional diagnostic nerve blocks if prior procedures produced significant pain relief.

Epidural (local anesthetic and/or steroid) injection is indicated for local and radicular pain under the following circumstances:

• There is no evidence of spinal cord compression, local neoplasm or other contraindications.
• Each injection should be based on a pre-procedure evaluation along with evidence of effectiveness rather than a pre-planned series of injections.
• Repeated treatments may be required during the initial stabilization phase (two to three injections) before pain relief is achieved. Thereafter, additional treatments should occur only after significant and lasting pain relief has been demonstrated from prior injections.

Peripheral Nerve Procedures

Nerve block procedures in the ambulatory setting are typically for the diagnostic purpose of identifying pain sources and informing future treatment plans. This policy applies to all peripheral nerves including genicular and facial nerves.

• The number of injections is limited to two for diagnostic purposes. To be considered medically necessary, there must be a specific symptom that this nerve block will alleviate.
• In certain circumstances there is a treatment benefit from nerve blocks. In these circumstances, the nerve block may be repeated no more than every six months if significant and lasting pain relief was previously accomplished.
• Nerve ablation is indicated after two prior nerve blocks have been performed on separate days with significant pain relief, or if a prior ablation produced significant pain relief and was performed at least six months prior.
• Occipital nerve blocks or ablations meeting the above criteria may be repeated every three months.

Tendon Sheath Injections (including insertion point)

There is insufficient evidence that this approach is safe and effective for the routine treatment of most conditions.

• Tendon sheath injections in general are not medically necessary for the exclusive purpose of pain relief, including for headaches and muscular pain.
• There is evidence that tendon sheath injections are medical necessary for certain specific conditions such as, but not limited to, elbow tendonitis, trigger finger and De Quervain’s tenosynovitis. In these conditions, the treatment is typically limited to one injection after six or more months of conservative treatment (e.g., NSAIDS, PT, rest, stretching) has failed to improve the discomfort.
• This procedure is not equivalent to trigger point injections.

Imaging Guidance

Fluoroscopy is medically necessary for the identification of structures in the majority of procedures but is not required to localize the knee joint for the purpose of aspiration or injection.

Ultrasound: Ultrasound (“US”) guidance may improve accuracy of needle placement in joints that are difficult to access.

US guidance⁵ is of greatest use for joints or other periarticular spaces that are especially difficult to enter based upon external landmarks alone. These regions and the recommended US approach include:

• Carpal tunnel (direct or indirect)
• Metacarpophalangeal joints (direct)
• Hip joint (direct or indirect)
• Sacroiliac joint (direct)
• Subtalar joint (direct)
• Metatarsophalangeal joints (direct)

US guidance may be of benefit in the following clinical circumstances based on factors, including cost, expertise of the clinician, use of reliable anatomic landmarks, typical industry standards, and the prior success of unguided procedures:

• Posterior glenohumeral (GH) joint (direct or indirect)
• Subacromial bursa (direct or indirect)
• Elbow joint (direct or indirect)
• Wrist (radiocarpal) joint (direct or indirect)
• De Quervain tendinopathy (direct)
• Trigger finger (direct)
• Baker's cyst (direct or indirect)
• Tibiotalar joint (direct or indirect, after failure of unguided procedure)

US guidance is generally not necessary in the following joints:

• Acromioclavicular joint
• Knee (except in individuals with obesity)
• Tibiotalar joint

However, ultrasound guidance of the knee for the injection of viscosupplementation, with intraarticular hyaluronic acid derivatives, will be permitted to limit possible extravasation of the agent outside the joint space. Ultrasound guidance of the knee for corticosteroid injections is not considered medically necessary to facilitate injection.

Localization of the occipital nerve is not considered medically necessary to facilitate injection.

Procedural Conscious Sedation

Sedation is medically necessary for cervical procedures. It is also medically necessary for radiofrequency ablation at any spinal level when multiple injections are required for a procedure, or when multiple procedures are performed during the same encounter. Procedural Conscious Sedation for any other procedure is not medically necessary in the absence of well-documented and compelling clinical reasons, such as previously documented pain intolerance, anxiety etc.

Joint Specific Procedures

Genticulate artery embolization is investigational and not medically necessary for knee pain. There is insufficient evidence that pain relief is produced safely and reliably by this procedure.

Applicability

The Pain Alleviating Procedures Practice Guidelines are applicable to the following product lines/health plans:

• Commercial
• Medicare Advantage
• Medi-Cal

Definitions

1. Diagnostic Injection is a medical procedure where a substance, often an anesthetic, is injected into a specific area of the body to help pinpoint the source of pain or other symptoms, thereby aiding in diagnosis.
2. Therapeutic Injection is a medical procedure where medication is injected into a specific area (like a joint, muscle, or nerve) to treat pain, inflammation, or other conditions. 

References 

1. Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 1 Efficacy: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations
   Anesthesia & Analgesia: March 2017 - Volume 124 - Issue 3 - p 821-830
2. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. Headache 2013; 53:437.
3. Robbins MS, Robertson CE, Kaplan E, et al. The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache. Headache 2016; 56:240.
4. US Food & Drug Administration: 510(k) Premarket Notification
5. Bruyn G, UpToDate, Musculoskeletal ultrasonography: Guided injection and aspiration of joints and related structures, May 20, 2021.

Purpose

Provide an evidence-based clinical policy for appropriate administration of Pegfilgrastim in the outpatient setting.

Background

Pegfilgrastim is an FDA approved leukocyte growth factor indicated to:

1. Decrease the incidence of infection, as manifested by febrile neutropenia, in patients with non-myeloid malignancies receiving myelosuppressive anti-cancer drugs associated with a clinically significant incidence of febrile neutropenia.
2. Increase survival in patients acutely exposed to myelosuppressive doses of radiation (Hematopoietic Subsyndrome of Acute Radiation Syndrome).
   Neulasta (J2506) is the reference medication initially developed with 7 biosimilar medications currently available Fulphila (Q5108), Fylnetra (Q5130) , Nyvepria (Q5122), Rolvedon (J1449), Stimufend (Q5127), Udenyca (Q5111), Ziextenzo (Q5120). Neulasta is the only agent currently available for use through a Neulasta Onpro® kit (96377) on-body injector (OBI); CPT code J2505 was the brand non-specific code retired in 2022.

Policy

Self-administration of leukocyte growth factors is appropriate for many, but not all patients.    There are many situations in which it is not practical or possible for a patient to self-administer injectable medications including, but not limited to, weakness, general malaise, lacking adequate vision or dexterity, etc.   These and similar circumstances may be present during the time of cancer treatment or anticipated based on clinical factors and the nature of the treatment being rendered.  It is the position of UCLA Health that professional administration of pegfilgrastim is the preferred method of delivery when self-administration is not possible or practical for an individual patient.  Professional administration includes the use of on-body applicators (On-Pro) which may be the most appropriate method for some patients.

Applicability

Relevant Product lines/Health Plans:
 

References

Neulasta FDA prescribing information

Purpose

Establish an evidence based clinical policy for Radiofrequency Ablation of Leiomyoma’s (Fibroids) in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers.

Background

Radiofrequency ablation of a tumor involves the delivery of high-frequency alternating current to induce thermal injury of target tissue. It may be performed percutaneously, transcervically, or surgically via laparoscopy or laparotomy; the procedure is performed with CT, MRI, or ultrasound guidance.

Policy

Radiofrequency ablation for uterine leiomyomas is indicated when ALL of the following are present:

1. Leiomyomas are documented by imaging study (e.g., ultrasound) or hysteroscopy and Fibroids and are less than 10 cm in any diameter.  Uterine size does not exceed 16 weeks’ gestation.
2. Patient desires uterine conservation, and has been advised that infertility rates from this procedure are unknown.
3. Patient is premenopausal.
4. Patient has experienced persistent symptoms (3 months or greater in duration) directly attributed to presence of leiomyomas, as indicated by one or more of the following:
   1. Abnormal uterine bleeding unresponsive to conservative management (e.g., hormonal therapy)
   2. Dyspareunia (painful intercourse)
   3. Infertility
   4. Iron deficiency anemia
   5. Pelvic pain or pressure
   6. bulk-related pelvic pain, pressure or discomfort
   7. Urinary symptoms referable to compression of the ureter or bladder, and/or dyspareunia).
5. Testing has ruled out other potential causes for symptoms.

Applicability

This policy applies to the following procedures:

• Transcervical radiofrequency ablation with ultrasound guidance (e.g., the Sonata System)
• Open surgical procedures
• Laparoscopic (e.g., the Acessa System)

ACOG American College of Gynecology – Endometrial Ablation

References

1. Chudnoff SG, Berman JM, Levine DJ, Harris M, Guido RS, Banks E. Outpatient procedure for the treatment and relief of symptomatic  uterine myomas. Obstetrics & Gynecology 2013;121(5):1075-1082. DOI: 10.1097/AOG.0b013e31828b7962.
2. Berman JM, et al. Three-year outcome of the halt trial: a prospective analysis of radiofrequency volumetric thermal ablation of myomas. Journal of Minimally Invasive Gynecology 2014;21(5):767-774. DOI: 10.1016/j.jmig.2014.02.015.
3. Brucker SY, Hahn M, Kraemer D, Taran FA, Isaacson KB, Kramer B. Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy. International Journal of Gynaecology and Obstetrics 2014;125(3):261-265. DOI: 10.1016/j.ijgo.2013.11.012.
4. Guido RS, Macer JA, Abbott K, Falls JL, Tilley IB, Chudnoff SG. Radiofrequency volumetric thermal ablation of fibroids: a prospective, clinical analysis of two years' outcome from the Halt trial. Health and Quality of Life Outcomes 2013;11(1):139. DOI: 10.1186/1477-7525-11-139.
5. Lethaby AE, Vollenhoven BJ. An evidence-based approach to hormonal therapies for premenopausal women with fibroids. Best Practice and Research. Clinical Obstetrics and Gynaecology 2008;22(2):307-331. DOI: 10.1016/j.bpobgyn.2007.07.010 

Purpose

Establish an evidence based clinical policy for weight management and obesity management in the UCLA managed care population in order to standardize care and processes across settings, specialties, health plans, lines of business, providers and UM reviewers. 

Background

According to the National Institute of Diabetes and Digestive and Kidney Diseases_¹, a person whose weight is higher than what is considered to be a normal weight for a given height is described as being overweight or having obesity. 

According to 2017–2018 data from the National Health and Nutrition Examination Survey (NHANES):

• Nearly 1 in 3 adults (30.7%) are overweight.
• More than 2 in 5 adults (42.4%) have obesity.
• About 1 in 11 adults (9.2%) have severe obesity.

According to 2017–2018 NHANES data:

• About 1 in 6 children and adolescents ages 2 to 19 (16.1%) are overweight.
• Almost 1 in 5 children and adolescents ages 2 to 19 (19.3%) have obesity.
• About 1 in 16 children and adolescents ages 2 to 19 (6.1%) have severe obesity.

Using Body Mass Index (BMI) to Estimate Overweight and Obesity

BMI is a tool to estimate and screen for overweight and obesity in adults and children. BMI is defined as weight in kilograms divided by height in meters squared. BMI is related to the amount of fat in the body. A high amount of fat can raise the risk of many health problems. A health care professional can determine if a person’s health may be at risk because of his or her weight.

Adults
The table below shows BMI ranges for overweight and obesity in adults 20 and older. 

BMI of Adults Ages 20 and Older:

Adults with obesity are at increased risk for many other serious health conditions such as heart disease, stroke, type 2 diabetes, some cancers, and poorer mental health.²  

The American College of Cardiology (ACC) and the American Heart Association (AHA) collaborated with the National Heart, Lung, and Blood Institute (NHLBI) to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults. The Full Panel Report contains background and additional material related to content, methodology, evidence synthesis, rationale, and references and is supported by the NHLBI Systematic Evidence Review, which can be found at:

The ACC/AHA – NHLBI guideline recommends evaluation of metrics, determination of patient’s need to lose weight, advise to avoid weight gain and address and treat other risk factors, access readiness to make lifestyle changes to achieve weight loss, determine weight loss and health goals and intervention strategies, and initiate or refer for a comprehensive lifestyle intervention program as initial steps for management. An energy deficit (caloric restriction, increased physical activity, or both) is required for weight loss.

The algorithm provides guidance on Comprehensive Lifestyle Intervention (Boxes 11a and 11b):

Box 11a. Offer or Refer for High-Intensity Comprehensive Lifestyle Intervention
The most effective behavioral weight loss treatment is an in-person, high-intensity (ie, ≥14 sessions in 6 months) comprehensive weight loss intervention provided in individual or group sessions by a trained interventionist† (CQ4). The principal components of an effective high intensity, on-site comprehensive lifestyle intervention include 1) prescription of a moderately reduced-calorie diet, 2) a program of increased physical activity, and 3) the use of behavioral strategies to facilitate adherence to diet and activity recommendations. As shown in CQ4, comprehensive lifestyle intervention consisting of diet, physical activity, and behavior therapy produces average weight losses of approximately 8 kg in a 6-month period of frequent, in-person treatment. This approximates losses of 5%-10% of initial weight. The observed average weight loss of approximately 8 kg includes people who have variable weight loss (ie, some more and some less than average), so accurate prediction of individual weight loss is not possible. After 6 months, most patients will equilibrate (caloric intake balancing energy expenditure) and will require adjustment of energy balance if they are to lose additional weight. As demonstrated in CQ4, continued intervention contact after initial weight loss treatment is associated with better maintenance of lost weight (Box 15).

Box 11b. Options for Alternative Modes of Delivery of Lifestyle Intervention
In primary care offices where frequent, in-person individual or group sessions led by a trained interventionist† or a nutrition professional* are not possible or available by referral, the physician may consider alternative modes of delivery. As found in CQ4, emerging evidence supports the efficacy, albeit with less weight loss, of electronically delivered interventions (eg, by Internet or telephone) that provide personalized feedback by a trained interventionist† and of some commercial programs that provide counseling (face-to-face or telephonic) with or without prepackaged meals. The Expert Panel recommends, by expert opinion, that physicians may refer to these alternative sources provided their outcomes are supported by scientific evidence of safety and efficacy. An additional option if a high-intensity comprehensive lifestyle intervention program is not available or feasible is referral to a nutrition professional* for dietary counseling.

Policy

The patient should be evaluated and weight and height calculated in order to determine Body Mass Index (BMI). If the patient is determined to be overweight or obese, then the physician shall obtain a history of weight and lifestyle interventions used by the patient for weight loss.  The physician shall then discuss Intervention Strategies with the patient.

Box 9: Determine Weight Loss and Health Goals and Intervention Strategies
Clinician and patient devise weight loss and health goals and comprehensive lifestyle treatment strategies to achieve these goals.
Recommended goals for weight loss: A realistic and meaningful weight loss goal is an important first step. Although sustained weight loss of as little as 3%-5% of body weight may lead to clinically meaningful reductions in some cardiovascular risk factors, larger weight losses produce greater benefits. The Expert Panel recommends as an initial goal the loss of 5%-10% of baseline weight within 6 months.
Recommended methods for weight loss: Weight loss requires creating an energy deficit through caloric restriction, physical activity, or both. An energy deficit of ≥500 kcal/d typically may be achieved with dietary intake of 1200-1500 kcal/d for women and 1500-1800 kcal/d for men. The choice of calorie-restricted diet can be individualized to the patient's preferences and health status (CQ3). Very-low-calorie diets (<800 kcal/d) should be used only in limited circumstances in a medical care setting where medical supervision and a high intensity lifestyle intervention can be provided. If a specialized diet for CVD risk reduction, diabetes, or other medical conditions is also prescribed, referral to a nutrition professional* is recommended (CQ3).
Recommendations for management of medical conditions during weight loss: While weight loss treatment is ongoing, manage risk factors such as hypertension, dyslipidemia, and other obesity-related conditions. This includes monitoring the patient's requirements for medication change as weight loss progresses, particularly for antihypertensive medications and diabetes medications that can cause hypoglycemia.

For purposes of participating in a weight loss program that involves a reduced calorie diet and increased physical activity, physician must provide documentation of:

• Type of calorie restriction including calorie goals
• Length of time that patient has been participating in this calorie restricted program
• Name of program, if a “formal” program is being followed
• Amount of exercise and type of exercise which patient is doing
• Length of time that patient has been participating in exercise program

It is the policy of UCLA Medical Group that there must be documentation that patient is participating in both calorie restriction and increased physical activity to cause an energy deficit for at least 6 months over the past 12 months, prior to initiation of medication as adjuvant therapy for weight loss for obesity (including GLP-1 Receptor Agonists).

There are certain clinical scenarios where an accelerated time course may be appropriate due to underlying medical conditions that prohibit the patient from engaging in physical activity or require the use of medications that lead to weight gain. In these cases approval for adjuvant medication for weight loss may be appropriate on a case-by-case basis.

Once medication is initiated as adjuvant therapy for weight loss for obesity, there should be documentation of discussion of side effects, contraindications, and alternatives of proposed medication. In addition, the patient shall be educated that per FDA guidelines, medication dose shall be increased up to the maximum allowed amount to facilitate weight loss as long as it is tolerated by the patient. Per FDA recommendations, the maximum dose should be initiated no later than week 17 of therapy. Medication renewal will be based on positive response to therapy regardless of current dose.

Renewal of medication shall require documentation of positive response to therapy with continued documentation of participation in calorie restriction and engagement in physical activity. Initial renewal, which shall occur no later than 6 months from initiation of therapy, must document that the patient has lost > 5% of baseline weight (adults) or baseline BMI (pediatrics). Subsequent renewal requests must document that patient has lost weight and/or maintained weight loss on therapy.

Separate from adjuvant medical therapy, UCLA Medical Group offers access several programs in which patients may be eligible for participation based on comorbidities and other enrollment criteria:

• UCLA Healthier Weight Management Program – an 8-week course meeting with dieticians and physicians. UCLA Medical Group subsidizes part of the cost of this program; the patient also has a share of cost. In-person as well as Telehealth sessions (including asynchronous sessions) are available.
• Referral to Center for Obesity (COMET) REF758. While this program is also referral for surgical management for Obesity, there is also a physician led nutritional component.
• Referral to Clinical Pharmacist / UCMyRx REF729– available for patients who are overweight or obese and have comorbidities of prediabetes, diabetes, or hypertension
• Referral to Clinical Nutrition – Medical Nutrition Counseling REF161 – for individual counseling for patients

Applicability

Relevant Product lines/Health Plans:
 

References

1. Overweight & Obesity Statistics
2. Adult Obesity Prevalence Maps
3. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults