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 overweight 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.

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

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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, E66.8 – 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)

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.

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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.

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.

Nutritional Counseling for Patients with Incurable Cancer

In a systematic review and meta-analysis, Ueshima et al (2023) examined if 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. Nutrition counseling was caried out by registered dietitians and/or nutritional specialists using any method, 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 used the Cochrane Risk of Bias 2 tool. Meta-analysis was carried out 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 nutrition counseling increased energy and protein intake; however, total certainty of evidence (CE) was low. Body-weight was not improved by nutrition counseling. The authors concluded that nutrition 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, nutrition counseling is a non-invasive treatment strategy that should be introduced early for nutrition intervention for patients with cancer. This review did not find sufficient evidence for the effect of nutrition counseling on QoL. These researchers stated that low-quality and limited evidence was identified regarding the impact of nutrition counseling for patients with cancer, and further research is needed.

References

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