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Clinical Policy Bulletin:
Nutritional Counseling
Number: 0049


Policy

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., licensed nutritionist, registered dietician, or other qualified licensed health professionals such as nurses who are trained in nutrition) recognized under the plan.

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

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 (i) cardiovascular disease, (ii) diabetes mellitus, (iii) hypertension, (iv) kidney disease, (v) eating disorders, (vi) gastrointestinal disorders, (vii) seizures (i.e., ketogenic diet), and other conditions (e.g., chronic obstructive pulmonary disease) based on the efficacy of diet and lifestyle on the treatment of these diseased states.  Registered dietitians, working in a coordinated, multi-disciplinary 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.

De Luis et al (2009) assessed the utility of a hypo-caloric diet with Optisource versus nutritional counseling in obese patients with an indication of replacement surgery for degenerative osteoarthritis.  A total of 36 patients were randomized into 2 groups: (i) diet I with lunch and dinner substituted by 2 Optisource [1,109.3 kcal/day, 166.4 g of carbohydrates (60 %), 63 g of proteins (23 %), 21.3 g of lipids (17 %)] and (ii) diet II with nutritional counseling with a decrease of 500 cal/day from the previous dietary intake.  Before and 3 months after treatment, a nutritional and biochemical study was performed.  A total of 19 patients were randomized in group (i) and 17 patients in group (ii).  All patients in group (i) and 14 patients in group (ii) finished the study.  Weight loss was higher in group (i) than group (ii) (7.7 [4.7] versus 3.92 [3.32] kg; p = 0.05), with a significant decrease of homeostasis model assessment (HOMA) and diastolic blood pressure in group (i).  Decreases of body mass index (-2.9 [1.8] versus -1.4 [0.9]; p = 0.05), fat mass (-3.8 [3.4] versus -2.3 [1.7] kg; p = 0.005) and HOMA (-2.0 [2.2] versus -0.4 [1.82]; p = 0.05) were higher in group (i) than group (ii).  The authors concluded that obese patients with chronic osteoarthritis treated with a mixed diet supplemented with a commercial hypo-caloric formula improved weight, fat mass and HOMA in a better way than patients treated with a dietary counseling alone.

There is a lack of reliable evidence for nutritional interventions as a treatment for asthma.  Ahnert and colleagues (2010) employed relevant data bases to collect and evaluate guidelines, meta-analyses, and reviews as well as primary studies dealing with asthma therapy for children and adolescents.  Treatment approaches whose effectiveness with regard to bronchial asthma was empirically verified (i.e., evidence-based) were identified (medical and diagnostic procedures as well as drug trials were excluded from the analysis).  A total of 152 methodically sound studies referring to asthma treatment of children and adolescents were selected.  Strong evidence was found for patient education, parent education, exercise therapy, inhalation, and tobacco withdrawal.  Nutritional counseling and avoidance of allergens showed limited evidence.  Breathing exercises, climate therapy, clinical social work (legal and social counseling services, vocational re-integration counseling, aftercare), integration counseling, psychotherapy, and relaxation techniques showed inconsistent evidence.  No evidence was found for alternative medicine.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
90951
90952
90953
90954
90955
90956
90957
90958
90959
90963
90964
90965
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
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):
314.00 Attention deficit disorder, without mention of hyperactivity
314.01 Attention deficit disorder, with hyperactivity
493.00 - 493.92 Asthma
780.71 Chronic fatigue syndrome
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.
  34. Dy SM, Lorenz KA, Naeim A, et al. Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea. J Clin Oncol. 2008;26(23):3886-3895.
  35. Kuzma AM, Meli Y, Meldrum C, et al. Multidisciplinary care of the patient with chronic obstructive pulmonary disease. Proc Am Thorac Soc. 2008;5(4):567-571.
  36. Baldwin C, Weekes CE. Dietary advice for illness-related malnutrition in adults. Cochrane Database Syst Rev. 2008;(1):CD002008.
  37. De Luis DA, Izaola O, García Alonso M, et al. Randomized clinical trial between nutritional counselling and commercial hypocaloric diet in weight loss in obese patients with chronic arthropathy. Med Clin (Barc). 2009;132(19):735-739.
  38. Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: A randomised trial. Thorax. 2009;64(4):326-331.
  39. Herpertz-Dahlmann B, Salbach-Andrae H. Overview of treatment modalities in adolescent anorexia nervosa. Child Adolesc Psychiatr Clin N Am. 2009;18(1):131-145.
  40. Molenaar EA, van Ameijden EJ, Vergouwe Y, et al. Effect of nutritional counselling and nutritional plus exercise counselling in overweight adults: A randomized trial in multidisciplinary primary care practice. Fam Pract. 2010;27(2):143-150.
  41. Ahnert J, Löffler S, Müller J, Vogel H. Systematic literature review on interventions in rehabilitation for children and adolescents with asthma bronchiale. Rehabilitation (Stuttg). 2010;49(3):147-159.
  42. Rueda JR, Solà I, Pascual A, Non-invasive interventions for improving well-being and quality of life in patients with lung cancer. Cochrane Database Syst Rev. 2011;9:CD004282.
  43. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin 2012;62(4):242-274.
  44. Louzada ML, Campagnolo PD, Rauber F, Vitolo MR. Long-term effectiveness of maternal dietary counseling in a low-income population: A randomized field trial. Pediatrics. 2012;129(6):e1477-e1484.
  45. Langius JA, Zandbergen MC, Eerenstein SE, et al. Effect of nutritional interventions on nutritional status, quality of life and mortality in patients with head and neck cancer receiving (chemo)radiotherapy: A systematic review. Clin Nutr. 2013;32(5):671-678.


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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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