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Clinical Policy Bulletin:
Nutritional Counseling
Number: 0049


Policy

  1. Aetna considers nutritional counseling medically necessary for chronic disease states in which dietary adjustment has a therapeutic role, when it is prescribed by a physician and furnished by a provider (e.g., a registered dietician, licensed nutritionist or other qualified licensed health professional such as nurses who are trained in nutrition) recognized under the plan.

  2. Aetna considers nutritional counseling of unproven value for conditions that have not been shown to be nutritionally related, including but not limited to chronic fatigue syndrome and attention-deficit hyperactivity disorder. 

Note: In all circumstances, the intent of this policy is to permit the nutritional counselor to function as a consultant to evaluate the member and coordinate ongoing care with the referring physician.



Background

Medical nutrition therapy provided by a registered dietitian involves the assessment of the person’s overall nutritional status followed by the assignment of individualized diet, counseling, and/or specialized nutrition therapies to treat a chronic illness or condition. Medical nutrition therapy has been integrated into the treatment guidelines for a number of chronic diseases, including (1) cardiovascular disease, (2) diabetes mellitus, (3) hypertension, (4) kidney disease, (5) eating disorders, (6) gastrointestinal disorders, (7) seizures (i.e., ketogenic diet), and other conditions based on the efficacy of diet and lifestyle on the treatment of these diseased states. Registered dietitians, working in a coordinated, multidisciplinary team effort with the primary care physician, take into account a person’s food intake, physical activity, course of any medical therapy including medications and other treatments, individual preferences, and other factors.
 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
90918
90919
90920
90921
90922
90923
90924
90925
97802
97803
97804
Other CPT codes related to the CPB:
99401 - 99412
HCPCS codes covered if selection criteria are met:
G0108 Diabetes outpatient self-management training services, individual, per 30 minutes
G0109 Diabetes self-management training services, group session (2 or more), per 30 minutes
G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in the same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
G0308 ESRD related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month
G0309 ESRD related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month
G0310 ESRD related services during the course of treatment, for patients under 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month
G0311 ESRD related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month
G0312 ESRD related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month
G0313 ESRD related services during the course of treatment, for patients between 2 and 11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month
G0314 ESRD related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month
G0315 ESRD related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2 or 3 face-to-face physician visits per month
G0316 ESRD related services during the course of treatment, for patients between 12 and 19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month
G0317 ESRD related services during the course of treatment, for patients 20 years of age and over; with 4 or more face-to-face physician visits per month
G0318 ESRD related services during the course of treatment, for patients 20 years of age and over; with 2 or 3 face-to-face physician visits per month
G0319 ESRD related services during the course of treatment, for patients 20 years of age and over; with 1 face-to-face physician visit per month
S9470 Nutritional counseling, dietitian visit
Other HCPCS codes related to the CPB:
S9449 Weight management classes, non-physician provider, per session
S9452 Nutrition classes, non-physician provider, per session
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
780.71 Chronic fatigue syndrome
314.00 Attention deficit disorder, without mention of hyperactivity
314.01 Attention deficit disorder, with hyperactivity
Other ICD-9-CM codes related to the CPB:
250.00 - 250.93 Diabetes Mellitus
261 Nutritional marasmus
263.0 - 263.9 Malnutrition
272.0 - 272.4 Hypercholesterolemia/hyperglyceridemia/hyperlipidemia/hyperchylomicronemia
278.00 - 278.01 Obesity (non-covered by HMO plans)
307.1 Anorexia nervosa
307.50 - 307.59 Eating disorders
327.23 Obstructive sleep apnea (adult) (pediatric)
345.00 - 345.91 Epilepsy and recurrent seizures
401.0 - 405.99 Hypertensive disease
410.00 - 414.9 Ischemic heart disease
416.0 - 416.9 Chronic pulmonary heart disease
425.0 - 425.9 Cardiomyopathy
428.0 - 428.9 Heart failure
429.0 Myocarditis, unspecified
429.1 Myocardial degeneration
429.2 Cardiovascular disease, unspecified
429.3 Cardiomegaly
531.00 - 537.89 Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and duodenitis, disorders of function of stomach, and other disorders of stomach and duodenum
555.0 - 564.9 Regional enteritis, ulcerative colitis, vascular insufficiency of intestines, other and unspecified non-infectious gastroenteritis and colitis, intestinal obstruction, diverticula of intestine, and functional digestive disorders, not elsewhere classified
569.60 - 579.9 Colostomy and enterostomy complications, other specified disorders of intestine, and other diseases of digestive system
580.0 - 599.89 Glomerulonephritis, nephrotic syndrome, nephritis, renal failure, infections of kidney, calculus of kidney and ureter, and disorders of bladder
642.00 - 642.94 Hypertension complicating pregnancy, childbirth, and the puerperium
646.20 - 646.24 Renal disease in pregnancy childbirth, and the puerperium
648.80 - 648.84 Abnormal glucose tolerance complicating pregnancy, childbirth, and the puerperium
751.0 - 751.9 Congenital anomalies of digestive system
753.0 - 753.3 Congenital anomalies of kidney
780.39 Other convulsions
783.0 - 783.43 Symptoms concerning nutrition, metabolism, and development
V65.3 Dietary surveillance and counseling
V69.1 Inappropriate diet and eating habits


The above policy is based on the following references:
  1. American Dietetic Association. Position of the American Dietetic Association: Medical nutrition therapy and pharmacotherapy. J Am Diet Assoc. 1999;99:227-230.
  2. American Dietetic Association. Position of the American Dietetic Association: Cost-effectiveness of medical nutrition therapy. J Am Diet Assoc. 1995;95:88-91.
  3. National Institutes of Health (NIH), National Heart Lung and Blood Institute (NHLBI). Summary of the Second Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II). JAMA. 1993;269:3015-3023.
  4. American Dietetic Association. Nutrition recommendations and principles for people with diabetes mellitus. J Am Diet Assoc. 1994;94:504-506.
  5. National Institutes of Health, National Heart Lung and Blood Institute. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The Fifth Report of the National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med. 1993;153:154-183.
  6. Becker AE, Grinspoon SK, Klibanski A, et al. Eating disorders. N Engl J Med. 1999;340(14):1092-1098.
  7. Gabbe SG. The gestational diabetes mellitus conferences. Three are history: Focus on the fourth. Diabetes Care. 1998;21(Suppl 2):B1-B2.
  8. Gerber J. Implementing quality assurance programs in multigroup practices for treating hypercholesterolemia in patients with coronary artery disease. Am J Cardiol. 1997;80(8B):57H-61H.
  9. Bakx JC, Stafleu A, van Staveren WA, et al. Long-term effect of nutritional counseling: A study in family medicine. Am J Clin Nutr. 1997;65(6 Suppl):1946S-1950S.
  10. van Weel C. Morbidity in family medicine: The potential for individual nutritional counseling, an analysis from the Nijmegen Continuous Morbidity Registration. Am J Clin Nutr. 1997;65(6 Suppl):1928S-1932S.
  11. Fitch J, Garcia RE, Moodie DS, et al. Influence of cholesterol screening and nutritional counseling in reducing cholesterol levels in children. The American Heart Association. Clin Pediatr (Phila). 1997;36(5):267-272.
  12. Dodge RE. Nutritional counseling and the physician. Am J Prev Med. 1997;13(2):73.
  13. Ford DE, Sciamanna C. Nutritional counseling in community office practices. Arch Intern Med. 1997;157(3):361-362.
  14. Lave JR, Ives DG, Traven ND, et al. Evaluation of a health promotion demonstration program for the rural elderly. Health Serv Res. 1996;31(3):261-281.
  15. Kannel WB. Preventive efficacy of nutritional counseling. Arch Intern Med. 1996;156(11):1138-1139.
  16. Soltesz KS, Price JH, Johnson LW, et al. Family physicians' views of the preventive services task force recommendations regarding nutritional counseling. Arch Fam Med. 1995;4(7):589-593.
  17. Tchekmedyian NS. Clinical approaches to nutritional support in cancer. Curr Opin Oncol. 1993;5(4):633-638.
  18. Grey N, Maljanian R, Staff I, Cruzmarino de Aponte M.  Improving care of diabetic patients through a collaborative care model. Conn Med. 2002;66(1):7-11.
  19. Cupisti A, Morelli E, D'Alessandro C, et al. Phosphate control in chronic uremia: Don't forget diet. J Nephrol. 2003;16(1):29-33. 
  20. Laviano A, Meguid MM, Rossi-Fanelli F. Cancer anorexia: Clinical implications, pathogenesis, and therapeutic strategies. Lancet Oncol. 2003;4(11):686-694.
  21. American Dietetic Association. Position of the American Dietetic Association: Integration of medical nutrition therapy and pharmacotherapy. J Am Diet Assoc. 2003;103(10):1363-1370.
  22. Anderson JV, Palombo RD, Earl R. Position of the American Dietetic Association: The role of nutrition in health promotion and disease prevention programs. J Am Diet Assoc. 1998;98(2):205-208.
  23. Pignone MP, Ammerman A, Fernandez L, et al. Counseling to promote a healthy diet in adults. A summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2003;24:75-92.
  24. U.S.. Preventive Services Task Force. Behavioral counseling in primary care to promote a healthy diet: Recommendations and rationale. Am J Prev Med. 2003;24(1):93-100.
  25. Burrowes JD. Incorporating ethnic and cultural food preferences in the renal diet. Adv Ren Replace Ther. 2004;11(1):97-104.
  26. Vazquez-Mellado J, Alvarez Hernandez E, Burgos-Vargas R. Primary prevention in rheumatology: The importance of hyperuricemia. Best Pract Res Clin Rheumatol. 2004;18(2):111-124.
  27. Petersen JL, McGuire DK. Impaired glucose tolerance and impaired fasting glucose--a review of diagnosis, clinical implications and management. Diab Vasc Dis Res. 2005;2(1):9-15.
  28. Jermendy G. Can type 2 diabetes mellitus be considered preventable? Diabetes Res Clin Pract. 2005;68 Suppl1:S73-S81.
  29. Norris SL, Zhang X, Avenell A, et al. Long-term non-pharmacological weight loss interventions for adults with prediabetes. Cochrane Database Syst Rev. 2005;(2):CD005270.
  30. Olendzki B, Speed C, Domino FJ. Nutritional assessment and counseling for prevention and treatment of cardiovascular disease. Am Fam Physician. 2006;73(2):257-264.
  31. American Dietetic Association. Position of the American Dietetic Association: Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and other eating disorders. J Am Diet Assoc. 2006;106(12):2073-2082.
  32. Mahlungulu S, Grobler LA, Visser ME, Volmink J. Nutritional interventions for reducing morbidity and mortality in people with HIV. Cochrane Database Syst Rev. 2007;(3):CD004536.
  33. Isenring EA, Bauer JD, Capra S. Nutrition support using the American Dietetic Association medical nutrition therapy protocol for radiation oncology patients improves dietary intake compared with standard practice. J Am Diet Assoc. 2007;107(3):404-412.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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