Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Many QualChoice plans exclude coverage for any nutritional counseling services.  Please consult your plan Explanation of Coverage or Summary Plan Description.

2)    For plans that cover nutritional counseling, QualChoice covers a limited number of nutritional counseling visits (1 unit = 15 min) for members who have certain chronic diseases:
- Celiac disease (8 units per lifetime)
- Chronic kidney disease (4 units annually)
- Chronic malabsorption (4 units annually)
- Chronic pancreatitis (4 units annually)
- Cleft palate (8 units per lifetime)
- Cystic fibrosis with intestinal manifestations (4 units annually)
- Lactose intolerance that is medically documented (8 units per lifetime)
- Multiple, severe (medically documented) food allergies (8 units per lifetime)
- Phenylketonuria (PKU) or other single-gene inborn errors of metabolism (8 units per lifetime)

Any diagnoses other than these will require preauthorization.

3)    Nutritional counseling for diabetics is included in global diabetic education programs, for members eligible for such programs.

4)    Nutritional counseling for purposes of weight loss is not covered, except for members in plans that have specific weight loss benefits.

5)    Nutritional counseling is not covered for purposes of encouraging healthy eating habits, general education about nutrition, or for conditions such as asthma attention deficit disorder, autism, chronic fatigue, fibromyalgia, or multiple chemical sensitivity syndrome.

1.  Nutritional counseling services provided by a licensed nutritionist, registered dietician, or registered nurse specially trained in nutrition to develop a dietary treatment plan to treat and/or manage certain chronic diseases are considered medically necessary and are covered when ALL of the following are true:

• Nutritional counseling is required for a disease in which patient self-management is an important component of treatment.
• Specific dietary modifications other than those widely recognized as comprising a healthy diet are required to manage the disease.
• There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.

2.  Nutritional counseling for diabetics is considered as part of standard diabetic education, and is not separately covered.

3.  Nutritional counseling is covered up to eight units, once per lifetime, for members with the following diseases:

• Celiac disease/gluten intolerance
• Cleft palate
• Lactose intolerance
• Multiple, severe food allergies
• Specific nutritional deficiencies
• Single gene inborn errors of metabolism
• Children with severe epilepsy refractory to antiepileptic drug treatment, who have been shown to improve with a ketogenic diet. (requires preauthorization to verify)

4.  Nutritional counseling is covered up to four units annually for members with the following diseases:

• Renal failure
• Chronic pancreatitis
• Cystic fibrosis with intestinal manifestations (E84.19)
• Malabsorption syndrome (for plans which exclude bariatric surgery, malabsorption related to bariatric surgery is not covered)
• Eating disorders, when BMI is less than 20 (requires preauthorization to verify)

Any other diagnoses (than those already listed above) requires preauthorization.

5.  Nutritional counseling is considered investigational for conditions that have not been shown to be nutritionally related, including but not limited to asthma, attention deficit disorder, autism, chronic fatigue syndrome, fibromyalgia and multiple chemical sensitivity syndrome.

Codes Used In This BI:

97802           Medical nutrition indiv in

97803           Med nutrition indiv subseq

97804           Medical nutrition group

G0270          MNT subs tx for change dx

S9470           Nutritional counseling, diet

Non-disease specific nutritional education such as general good eating habits, calorie control, or dietary preferences is not covered.

A registered dietitian provides nutritional counseling or medical nutrition therapy as prescribed by the primary care physician. The dietitian evaluates the patient’s food intake, physical activity, course of any medical therapy, including medications, and any individual preferences. An initial nutritional evaluation and short-term nutritional counseling may be appropriate as part of the overall medical management of documented metabolic conditions such as diabetes or phenylketonuria (PKU). Typically, this can be accomplished in two to three visits. Short-term evaluation and counseling should include doing an initial dietary work-up, counseling the patient about sample menu planning and teaching him or her about the impact of diet on the disease or condition. The goals of medical nutrition therapy are to promote health, reduce the incidence of preventable disease, and improve quality of life. Adherence to a medical nutrition plan of care and adaptation of other appropriate components of lifestyle changes may prevent or delay the need for pharmacotherapy or allow discontinuation of pharmacotherapy after a period of time.

There has been limited research on the effectiveness of nutritional counseling on patient outcomes in chronic disease.  Patients with certain metabolic diseases, such as phenylketonuria, must follow restricted diets on a lifelong basis to prevent deterioration from the disease.  Nutritional counseling assists these patients (or their parents) to understand what the lifelong diet must consist of.  Similarly, children with severe refractory epilepsy may benefit from a ketogenic diet, which can be taught to the parents by a registered dietician.  Nutritional counseling may assist a patient with an eating disorder to achieve an appropriate diet that prevents metabolic disorders from complicating treatment.  Dietary modification is routinely used in patients with moderate to severe chronic renal failure, though limited evidence has been developed on outcomes.

Diet modification has also been proposed as an intervention for the management of attention-deficit/hyperactivity disorder (ADHD), chronic fatigue syndrome (CFS), and idiopathic environmental intolerance (IEI). IEI, also known as multiple chemical sensitivity, is a chronic, polysymptomatic condition that cannot be attributed to organic disease. IEI is characterized by multiple functional symptoms in relation to environmental exposures. The more common environmental chemicals cited for triggering symptoms include car exhaust, perfumes, cigarette smoke and pesticides. Although allergic, immunotoxin, neurotoxic, cytotoxic, psychologic, sociologic, and iatrogenic theories have been proposed for both etiology and production of symptoms of IEI, there is an absence of scientific evidence to establish any of these mechanisms as definitive (American Academy of Allergy Asthma and Immunology [AAAAI], 1996, 2008).

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 reintegration counseling, and aftercare), integration counseling, psychotherapy, and relaxation techniques showed inconsistent evidence.

While nutritional counseling has been shown to reduce weight loss in patients undergoing chemotherapy for colorectal cancer, it has not been shown to affect disease outcome or functional performance.

1)    American Academy of Allergy Asthma and Immunology (AAAAI). Position Statement. Idiopathic environmental intolerances. © 1996􀅆2008 Accessed Dec 8, 2008. Available at URL address: http://www.aaaai.org/members/academy_statements/position_statements/ps35.asp

2)    American Academy of Family Physicians, American Dietetic Association. Nutrition Screening Initiative. A physician’s guide to nutrition in chronic disease management for older adults. Accessed Dec 3, 2004; Nov 27, 2007. Available at URL: http://www.aafp.org/PreBuilt/NSI_newbookletSMALLER.pdf

3)    American Academy of Family Physicians. American Dietetic Association. Nutrition Screening Initiative.  Congestive heart failure. Nutrition management for older adults. Accessed Nov 27, 2007. Available at URL address: http://www.aafp.org/PreBuilt/NSI_CHF.pdf

4)    American Dietetic Association. Position of the American Dietetic Association: nutrition intervention in the treatment of eating disorders. J Am Diet Assoc. 2011 Aug;111(8)

5)    Arcand JA, Brazel S, Joliffe C, Choleva M, Berkoff F, Allard JP, et al. Education by a dietitian in patients with heart failure results in improved adherence with a sodium-restricted diet: a randomized trial. Am Heart J. 2005 Oct; 150(4):716.

6)    Bailer J, Witthoft M, Paul C, Bayerl C, Rist F. Evidence for overlap between idiopathic environmental intolerance and somatoform disorders. Psychosom Med. 2005 Nov-Dec; 67(6):921-9.

8)    Becker AE, Grinspoon SK, Klibanski A, et al. Eating disorders. N Engl J Med.

1999; 340(14):1092-1098.

7)    Bossola M, Muscaritoli M, Tazza L, Giungi S, Tortorelli A, Fanelli FR, et al. Malnutrition in hemodialysis patients: what therapy? Am J Kidney Dis. 2005 Sep; 46(3):371-86.

8)    Cupisti A, Morelli E, and D’Alessandro C, et al. Phosphate control in chronic uremia: Don`t forget diet. J Nephrol. 2003; 16(1):29-33.

9)    Das-Munshi J, Rubin GJ, Wessely S. Multiple chemical sensitivities: review. Curr Opin Otolaryngol

Head Neck Surg. 2007 Aug; 15(4):274-80.

10) Dintinjana RD - Coll Antropol - 01-SEP-2008; 32(3): 737-40 Effects of nutritional support in patients with colorectal cancer during chemotherapy.
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.

11) Hayes Medical Technology Assessment.  Ketogenic Diet for Refractory Seizure Control, published 28 June 2011

12) Shephard RJ. Chronic fatigue syndrome. A brief review of functional disturbances and potential therapy. J Sports Med Phys Fitness. 2005 Sep; 45(3):381-92.

13) Taal:  Brenner and Rector’s The Kidney, 9th ed., “Nutrition and Peritoneal Dialysis”

14) Tchekmedyian NS. Clinical approaches to nutritional support in cancer. Curr Opin Oncol. 1993; 5(4):633-638.

15) Weekes CE, Emery PW, Elia M. Dietary counselling and food fortification in stable COPD: A randomized trial. Thorax. 2009; 64(4):326-331.

Addendum: 

1.     Effective 07/01/2017: Clarified coverage for single gene inborn errors of metabolism.

2.     Effective 01/01/2018: Clarified PA language.