Nutritional Counseling

Number: 0049

Policy

Aetna considers nutritional counseling a medically necessary preventive service for children and adults who are obese, and for adults who are overweight and have other cardiovascular disease risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome), 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 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 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

  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.

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) recomends 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 3 months after treatment, a nutritional and biochemical study was performed. A total of 19 patients were randomized in group 1 and 17 patients in group 2. All patients in group 1 and 14 patients in group 2 finished the study. Weight loss was higher in group 1 than group 2 (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 1. 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 1 than group 2.  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.

Su and colleagues (2016) stated that a growing number of studies and reviews have documented the impact of telemedicine on diabetes management.  However, no meta-analysis has assessed whether including nutritional counseling as part of a telemedicine program has a significant impact on diabetes outcomes or what kind of nutritional counseling is most effective.  Original research articles examining the effect of telemedicine interventions on HbA1c levels in patients with Type 1 or Type 2 diabetes were included in this study.  A literature search was performed and 92 studies were retained for analysis.  These researchers examined stratified results by differentiating interventions using no nutritional counseling from those that used nutritional counseling.  They further compared between nutritional counseling administered via short message systems (SMS) such as e-mail and text messages, and nutritional counseling administered via telephone or video-conference.  Telemedicine programs that include a nutritional component showed similar effect in diabetes management as those programs that do not.  Furthermore, subgroup analysis revealed that nutritional intervention via SMS such as e-mail and text messages is at least as equally effective in reducing HbA1c when compared to personal nutritional counseling with a practitioner over video-conference or telephone.  The authors concluded that the inclusion of nutritional counseling as part of a telemedicine program did not make a significant difference to diabetes outcomes.  Incorporating nutritional counseling into telemedicine programs via SMS was at least as effective as counseling via telephone or video-conference.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes
Code Code Description

Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":

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 physicial 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

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, E66.8 - 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)

The above policy is based on the following references:

  1. 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.
  2. 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.
  3. 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.
  4. American Dietetic Association. Nutrition recommendations and principles for people with diabetes mellitus. J Am Diet Assoc. 1994;94:504-506.
  5. American Dietetic Association. Position of the American Dietetic Association: Medical nutrition therapy and pharmacotherapy. J Am Diet Assoc. 1999;99:227-230.
  6. American Dietetic Association. Position of the American Dietetic Association: Cost-effectiveness of medical nutrition therapy. J Am Diet Assoc. 1995;95:88-91.
  7. 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.
  8. 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.
  9. Baldwin C, Weekes CE. Dietary advice for illness-related malnutrition in adults. Cochrane Database Syst Rev. 2008;(1):CD002008.
  10. Becker AE, Grinspoon SK, Klibanski A, et al. Eating disorders. N Engl J Med. 1999;340(14):1092-1098.
  11. Burrowes JD. Incorporating ethnic and cultural food preferences in the renal diet. Adv Ren Replace Ther. 2004;11(1):97-104.
  12. 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. 
  13. 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.
  14. Dodge RE. Nutritional counseling and the physician. Am J Prev Med. 1997;13(2):73.
  15. 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.
  16. 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.
  17. Ford DE, Sciamanna C. Nutritional counseling in community office practices. Arch Intern Med. 1997;157(3):361-362.
  18. Gabbe SG. The gestational diabetes mellitus conferences. Three are history: Focus on the fourth. Diabetes Care. 1998;21(Suppl 2):B1-B2.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. Jermendy G. Can type 2 diabetes mellitus be considered preventable? Diabetes Res Clin Pract. 2005;68 Suppl1:S73-S81.
  24. Kannel WB. Preventive efficacy of nutritional counseling. Arch Intern Med. 1996;156(11):1138-1139.
  25. 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.
  26. 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.
  27. 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.
  28. Laviano A, Meguid MM, Rossi-Fanelli F. Cancer anorexia: Clinical implications, pathogenesis, and therapeutic strategies. Lancet Oncol. 2003;4(11):686-694.
  29. LeFevre ML; U.S. Preventive Services Task Force. Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2014;161(8):587-593.
  30. 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.
  31. 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.
  32. 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.
  33. Moyer VA; U.S. Preventive Services Task Force. Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373-378.
  34. 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.
  35. 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.
  36. 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.
  37. 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.
  38. 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.
  39. 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.
  40. 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.
  41. 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.
  42. 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.
  43. Su D, McBride C, Zhou J, Kelley MS. Does nutritional counseling in telemedicine improve treatment outcomes for diabetes? A systematic review and meta-analysis of results from 92 studies. J Telemed Telecare. 2016;22(6):333-347.
  44. Tchekmedyian NS. Clinical approaches to nutritional support in cancer. Curr Opin Oncol. 1993;5(4):633-638.
  45. 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.
  46. US Preventive Services Task Force, Barton M. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics. 2010;125(2):361-367.
  47. 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.
  48. 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.
  49. Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: A randomised trial. Thorax. 2009;64(4):326-331.