Nutritional Counseling

Number: 0049

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses nutritional counseling.

1. Medical Necessity

   Aetna considers nutritional counseling a medically necessary preventive service for children and adults who are obese, and for adults who are over-weight and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome), when it is 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 medically necessary for other chronic disease states (e.g., diabetes mellitus, eating disorders, gastro-intestinal disorders, hypertension, kidney disease, seizures (i.e., ketogenic diet), and other conditions (e.g., chronic obstructive pulmonary disease) in which dietary adjustment has a therapeutic role, when it is 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.

2. Experimental, Investigational, or Unproven

   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: The use of NutrEval (an allergy test) that provides comprehensive functional and nutritional assessment is considered experimental, investigational, or unproven.

3. Policy Limitations and Exclusions

   Note: 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. Some plans require referrals for nutritional counseling. Please check benefit plan descriptions.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
CPT codes covered if selection criteria are met:
90951	End-stage renal disease (ESRD) related services monthly, for patients younger than 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
90952	with 2-3 face-to-face physician visits per month
90953	with 1 face-to-face physician visit per month
90954	End-stage renal disease (ESRD) related services monthly, for patients 2-11 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
90955	with 2-3 face-to-face physician visits per month
90956	with 1 face-to-face physician visit per month
90957	End-stage renal disease (ESRD) related services monthly, for patients 12-19 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
90958	with 2-3 face-to-face physician visits per month
90959	with 1 face-to-face physician visit per month
90963	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90964	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
90965	End-stage renal disease (ESRD) related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents
97802	Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803	re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804	group (2 or more individual(s)), each 30 minutes
CPT codes not covered for indications listed in the CPB:
NutrEval –no specific code
Other CPT codes related to the CPB:
99401 - 99412	Preventive medicine counseling
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
G0447	Face-to-face behavioral counseling for obesity, 15 minutes
G0473	Face-to-face behavioral counseling for obesity, group (2-10), 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-10 codes covered if selection criteria are met:
E66.01 - E66.2, E66.811 - E66.9	Obesity
E66.3	Overweight [covered for adults who are overweight, BMI greater than 25.0 kg. and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome)]
F50.00 - F50.9	Eating disorders
Z68.25 - Z68.29	Body mass index (BMI) adult, 25.0 – 29.9 kg. [covered for adults who have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome)]
Z68.30 - Z68.45	Body mass index (BMI) adult, 30.0 – 40+kg
Z68.53	Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age
Z68.54	Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
F90.0 - F90.9	Attention-deficit hyperactivity disorder
J45.20 - J45.909	Asthma
R53.82	Chronic fatigue, unspecified (chronic fatigue syndrome NOS)

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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 (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.

 

 

Nutritional Counseling and Cardiovascular Disease

Low et al. (2021) identified dietary counseling as a key nutritional strategy for improving cardiometabolic health conditions, although its effectiveness may vary based on factors such as the intensity of the counseling and the provider, an area that has not been thoroughly explored. In a systematic review and meta-analysis, the authors aimed to evaluate the impact of dietary counseling on cardiometabolic health in middle-aged and older adults, including subgroup analyses based on counseling intensity and provider type. A systematic search was conducted across four databases: PubMed, CINAHL Plus with Full Text, Cochrane Library, and EMBASE, resulting in data from 22 randomized controlled trials (RCTs), with 9 of these included in the meta-analysis. The results indicated that dietary counseling significantly reduced total cholesterol (TC) and fasting blood sugar (FBS) levels, but had no effect on triglycerides (TG) or low-density lipoprotein (LDL). Subgroup analysis revealed that high-intensity dietary counseling led to significant reductions in TG (weighted mean difference [WMD]: -0.24 mmol/L, 95% confidence intervals [CIs]: -0.40 to -0.09), TC (WMD: -0.31 mmol/L, 95% CIs: -0.49 to -0.13), LDL (WMD: -0.39 mmol/L, 95% CIs: -0.61 to -0.16), and FBS (WMD: -0.69 mmol/L, 95% CIs: -0.99 to -0.40), while medium and low-intensity counseling did not show favorable effects. Additionally, the type of counseling provider influenced the outcomes, with dietitians yielding different responses compared to other groups. Overall, the findings suggest that dietary counseling is an effective strategy for enhancing cardiometabolic health in middle-aged and older adults, particularly when emphasizing the intensity of the counseling.

The US Preventive Services Task Force (USPSTF) (2022) emphasizes the significance of addressing cardiovascular disease (CVD), which encompasses heart disease, myocardial infarction, and stroke, as it remains the leading cause of death in the United States. A substantial number of CVD cases can be prevented by targeting modifiable risk factors such as smoking, obesity, diabetes, hypertension, dyslipidemia, physical inactivity, and poor diet. Adults who follow national guidelines for a healthy diet and regular physical activity experience lower rates of cardiovascular morbidity and mortality compared to those who do not; however, most adults in the US fail to meet these dietary and activity recommendations. To update its 2017 recommendation, the USPSTF commissioned a review of the evidence regarding the benefits and harms of behavioral counseling interventions aimed at promoting healthy behaviors in adults without CVD risk factors. This population includes adults aged 18 and older who do not have known risk factors such as hypertension, dyslipidemia, impaired fasting glucose, or a 10-year CVD risk of 7.5% or greater. The USPSTF concludes with moderate certainty that behavioral counseling interventions provide a small net benefit in reducing CVD risk for these adults. Consequently, the USPSTF recommends that clinicians tailor the decision to offer or refer adults without CVD risk factors to behavioral counseling interventions focused on promoting a healthy diet and physical activity (C recommendation).

Nutritional Counseling and Diabetes 

Su and colleagues (2016) noted a growing body of research documenting the impact of telemedicine on diabetes management. However, no meta-analysis had yet assessed the significance of including nutritional counseling as part of a telemedicine program on diabetes outcomes or identified the most effective type of nutritional counseling. This study included original research articles that examined the effect of telemedicine interventions on HbA1c levels in patients with Type 1 or Type 2 diabetes. A literature search yielded 92 studies for analysis. The researchers differentiated between interventions that included nutritional counseling and those that did not, further comparing nutritional counseling delivered via short message systems (SMS), such as email and text messages, with counseling provided through telephone or video conferencing. The findings indicated that telemedicine programs incorporating a nutritional component had similar effects on diabetes management as those without. Additionally, subgroup analysis revealed that nutritional interventions delivered via SMS were at least as effective in reducing HbA1c levels as personal nutritional counseling conducted over video conferencing or telephone. The authors concluded that including nutritional counseling in telemedicine programs did not significantly improve diabetes outcomes, and that SMS-based nutritional counseling was at least as effective as traditional methods.

The ADA Standards of Care in Diabetes (2025) emphasize that there is no specific ideal percentage of calories from carbohydrates, proteins, or fats for individuals with diabetes; instead, macronutrient distribution should be tailored to each person's eating habits, preferences, and metabolic goals. Healthcare team members should enhance and support Medical Nutrition Therapy (MNT) by providing evidence-based guidance that enables individuals with diabetes to make healthy food choices that cater to their unique needs and promote overall health. Continuous education on diabetes and nutrition, along with appropriate support for implementing and maintaining healthy behaviors, is recommended. Research indicates that various eating patterns can effectively manage diabetes, with evidence derived from randomized controlled trials, prospective cohort studies, systematic reviews, and network meta-analyses. The most frequently recommended patterns include Mediterranean, DASH, low-fat, carbohydrate-restricted, vegetarian, and vegan diets. Until more robust evidence emerges regarding the benefits of different eating patterns, healthcare professionals should focus on the common elements of healthy diets, such as incorporating non-starchy vegetables, whole fruits, legumes, whole grains, nuts, seeds, and low-fat dairy, while minimizing red meat, sugar-sweetened beverages, sweets, refined grains, and processed foods. Referrals to and ongoing support from a registered dietitian nutritionist (RDN) are crucial for assessing the overall nutritional status of individuals with diabetes and collaboratively developing personalized meal plans that align with their overall treatment strategies, including physical activity and medication. Shared decision-making can be part of the nutrition care process to determine the best approach for executing the meal plan. For individuals with type 1 or type 2 diabetes who use insulin at mealtime, comprehensive and ongoing education about nutrition and the relationship between insulin administration and carbohydrate intake is essential. For those with variable meal schedules or carbohydrate consumption, regular education on the connection between carbohydrate intake and insulin needs is important, as well as guidance on using insulin-to-carbohydrate ratios for meal planning to help adjust insulin dosing for better glycemic control.

Nutritional Counseling and Weight Loss

The U.S. Preventive Services Task Force (USPSTF, 2012) recommends recommends screening all adults for obesity. The USPSTF recommends that clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. The USPSTF (2010) recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral intervention to promote improvement in weight status. 

The USPSTF (2014) recommended offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. This recommendation applies to adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome). In the studies reviewed by the USPSTF, the vast majority of participants had a BMI greater than 25 kg/m2.

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:

1. Diet 1 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
2. Diet 2 with nutritional counseling with a decrease of 500 cal/day from the previous dietary intake.

Before and three months after treatment, a nutritional and biochemical study was conducted involving a total of 36 patients, with 19 randomized into group 1 and 17 into group 2. All patients in group 1 and 14 patients in group 2 completed the study. Weight loss was significantly greater in group 1 compared to group 2, with an average loss of 7.7 kg (4.7) versus 3.92 kg (3.32) respectively (p = 0.05). Additionally, group 1 experienced significant decreases in homeostasis model assessment (HOMA) and diastolic blood pressure. Other notable reductions included body mass index (BMI), which decreased by -2.9 (1.8) in group 1 compared to -1.4 (0.9) in group 2 (p = 0.05), fat mass, which decreased by -3.8 (3.4) kg in group 1 versus -2.3 (1.7) kg in group 2 (p = 0.005), and HOMA, which decreased by -2.0 (2.2) in group 1 compared to -0.4 (1.82) in group 2 (p = 0.05). The authors concluded that obese patients with chronic osteoarthritis who were treated with a mixed diet supplemented with a commercial hypo-caloric formula showed greater improvements in weight, fat mass, and HOMA compared to those receiving dietary counseling alone.

The USPSTF (2018) for "Weight loss to prevent obesity-related morbidity and mortality in adults: Behavioral interventions" provide a Category Grade B recommendation that clinicians offer or refer adults with a body mass index (BMI) of 30 or higher (calculated as weight in kilograms divided by height in meters squared) to intensive, multicomponent behavioral interventions. "Using various modes of intervention delivery (group, individual, mixed, technology-based, and print-based), trials were generally designed to help participants achieve or maintain a 5% or greater weight loss through a combination of dietary changes and increased physical activity." As of December 2025, the USPSTF website notes that this topic is in the process of being updated and is pending a final recommendation statement.

Al-Nimr et al. (2020) highlighted the significant impact of obesity on the elderly and explored the effects of intensive nutrition counseling on diet quality and anthropometric measures in rural older adults with obesity. Conducted through a series of 12-week feasibility pilots at a community aging center in rural Northern New England, the study included participants aged 65 and older with a body mass index (BMI) of 30 kg/m² or higher, while excluding those with certain health conditions. Participants received weekly nutrition counseling from a registered dietitian nutritionist (RDN) and attended exercise sessions twice a week led by a physical therapist (PT). The primary outcomes measured were changes in diet quality, assessed using the Rapid Eating and Activity Assessment for Patients-Short Version (REAP-S) and the Automated Self-Administered 24-hour dietary recall (ASA-24), while secondary outcomes included changes in weight and waist circumference. The trial involved 23 subjects, with a mean age of 72.2 years and a mean BMI of 35.9 kg/m². Results showed significant improvements in diet quality, with REAP-S scores increasing by 3.53 points, and reductions in kilocalories, fat, saturated fat, sodium, added sugar, and alcohol intake. Additionally, participants experienced significant weight loss (−5.22 kg) and reductions in waist circumference (−6.88 cm). The authors concluded that intensive nutrition counseling effectively improved diet quality and reduced weight and waist circumference in this population.

Nutritional Counseling for Eating Disorders

McMaster et al. (2021) highlight that eating disorders (EDs) are complex mental illnesses necessitating medical, psychological, and dietary interventions for effective recovery. The objective of their review was to evaluate the existing evidence regarding dietetic interventions for adult outpatients with EDs and to assess the quality of this evidence. Systematic literature searches were performed across five databases (MEDLINE, PreMEDLINE, EMBASE, CINAHL, and PsycINFO) to identify studies comparing adults with EDs receiving dietetic interventions to those receiving only psychological interventions, those receiving a combination of dietetic and psychological interventions, or control groups. The searches yielded 3,078 results, ultimately identifying 10 articles that reported on 9 randomized controlled trials meeting the inclusion criteria. The quality of the evidence was evaluated using the Cochrane Risk-of-Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. GRADE assessments for studies involving individuals with anorexia nervosa indicated very low quality of evidence regarding outcomes such as weight, ED psychopathology, and ED behaviors, with no studies measuring nutritional changes. For studies involving participants with bulimia nervosa or binge eating disorder, only one study included a group receiving a combined evidence-based psychological and dietetic intervention, which demonstrated moderate-quality evidence for lower attrition rates, greater abstinence from ED behaviors, and an increase in meals eaten per week compared to standalone psychological or dietetic interventions. The authors concluded that while there is currently limited evidence to adequately assess the impact of dietetic interventions in outpatient treatment for adults with EDs, the available evidence supports clinical practice guidelines that recommend against delivering dietetic interventions as standalone treatments. They call for additional methodologically robust studies with larger sample sizes to better inform dietary treatment in EDs and to integrate such interventions into a multidisciplinary treatment approach.

Nutritional Counseling for Incurable Cancer

In a systematic review and meta-analysis, Ueshima et al. (2023) examined whether nutritional counseling by registered dietitians and/or nutritional specialists is recommended for adult patients with incurable advanced or recurrent cancer who are refractory to or intolerant of anti-cancer therapy. This systematic review analyzed randomized controlled trials (RCTs) of nutritional counseling in cancer patients older than 18 years, primarily those with stage-4 cancer. Nutritional counseling was carried out by registered dietitians and/or nutritional specialists using various methods, including group sessions, telephone consultations, written materials, and web-based approaches. These investigators searched the Medline (PubMed), Medline (OVID), Embase (OVID), CENTRAL, Emcare, and Web of Science Core Collection databases for studies published from 1981 to 2020. Two independent authors evaluated the risk of bias using the Cochrane Risk of Bias 2 tool. Meta-analysis was conducted for results and outcomes that allowed quantitative integration. The search yielded 2,376 studies, of which 7 examined 924 patients with cancer aged 24 to 95 years. The primary outcome of quality of life (QoL; a patient-reported outcome) was reported in 6 studies, 2 of which showed improvement with nutritional counseling. The other primary outcome of physical symptoms was reported in 2 studies, 1 of which showed improvement with nutritional counseling. Quantitative integration of both QoL and physical symptoms was difficult. A meta-analysis of energy and protein intake and body weight was conducted for secondary outcomes. Results showed that nutritional counseling increased energy and protein intake; however, the total certainty of evidence (CE) was low. Body weight was not improved by nutritional counseling. The authors concluded that nutritional counseling is shown to improve energy and protein intake in patients with incurable cancer. Although neither nutrient intake can be strongly recommended because of low CE, nutritional counseling is a non-invasive treatment strategy that should be introduced early for nutritional intervention for patients with cancer. This review did not find sufficient evidence for the effect of nutritional counseling on QoL. These researchers stated that low-quality and limited evidence was identified regarding the impact of nutritional counseling for patients with cancer, and further research is needed.

Oppermann et al. (2025) noted that radiotherapy (RT) is a common cancer treatment, and concurrent nutritional interventions can maintain nutritional status and improve clinical and supportive care outcomes. However, optimal nutritional interventions during RT are not firmly established. In a systematic review, these investigators examined the feasibility, safety, and effectiveness of dietary counseling interventions without oral nutrition supplements on health outcomes in adults receiving RT for cancer. Prospective studies that implemented nutritional counseling interventions during RT were identified from 4 databases from inception through December 2023. Feasibility, safety, and effectiveness were extracted from 32 articles that described 23 randomized and 4 non-randomized clinical trials. The interventions included individualized nutritional counseling (n = 14 articles), nutritional counseling plus exercise (n = 4), and nutritional counseling focused on increasing or reducing the intake of specific nutrients (n = 9). Studies targeted head and neck (n = 12), pelvic cancers (n = 14), and/or breast (n = 5) cancers. Control groups had variable designs and included general nutrition education and intervention as needed. Studies recruited 120 ± 104 participants (range of 26 to 468). Interventions tended to be feasible regarding retention and attendance at sessions, although feasibility metrics varied among different interventions. Most interventions were safe, with no studies reporting adverse events (AEs) attributable to dietary intervention. Individualized dietary counseling interventions tended to result in between-group differences favoring the intervention group in regard to improved nutritional status, maintenance or attenuation of loss of body mass, improved QoL, and reduced radiation-induced toxicities. Diets that encouraged or discouraged specific nutrients tended to recruit patients receiving radiation to the pelvic area and resulted in positive or neutral effects on gastrointestinal (GI) symptoms. The authors concluded that nutritional interventions appeared to be feasible, safe, and effective during RT for various symptom outcomes.

Nutritional Counseling for Asthma

Ahnert and colleagues (2010) highlighted the lack of reliable evidence for nutritional interventions as a treatment for asthma. They utilized relevant databases to collect and evaluate guidelines, meta-analyses, reviews, and primary studies related to asthma therapy for children and adolescents. The analysis focused on treatment approaches that had empirical evidence supporting their effectiveness in managing bronchial asthma, excluding medical and diagnostic procedures as well as drug trials. A total of 152 methodologically sound studies concerning asthma treatment in children and adolescents were selected. Strong evidence was found for patient education, parent education, exercise therapy, inhalation, and tobacco cessation. However, nutritional counseling and allergen avoidance were supported by limited evidence. Other interventions, such as breathing exercises, climate therapy, clinical social work, integration counseling, psychotherapy, and relaxation techniques, showed inconsistent evidence. No evidence was found to support alternative medicine approaches.

NutrEval Allergy Test

NutrEval is an allergy test that provides comprehensive functional and nutritional assessment including:

• Organic acids - providing insight into nutritional co-factor needs, digestive issues, cellular energy production, neurotransmitter metabolism, detoxification, and oxalates
• Oxidative stress - indicating problems with antioxidant capacity and oxidative damage
• Amino acids (AAs) - essential and non-essential AAs to indicate dietary intake, mal-digestion or mal-absorption, and AA metabolism; these can be assessed in either plasma or first morning void urine
• Essential and metabolic fatty acids (FAs) - reflecting dietary intake and metabolism of FAs measured in red blood cells to evaluate important FA imbalances
• Nutrient and toxic elements - providing a window into short-term exposures to various toxins along with direct evaluation of key minerals

However, there is a lack of evidence regarding the effectiveness of the NutrEval in improving healthcare outcomes.

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References