Medical Nutrition Therapy and Enteral Nutrition Products

Medical nutrition therapy (MNT) provided by a registered dietitian (RD) is a covered benefit for all lines of business for members who meet qualifying conditions. The Alliance will cover MNT for medically necessary conditions when prescribed by the medical doctor (MD), doctor of osteopathic medicine (DO), physician’s assistant (PA), nurse practitioner (NP), registered dietitian (RD) or non-contracted provider. In order for a provider to receive payment for services rendered, a prior authorization is required, and services must be administered by a registered dietitian. A Treatment Authorization Request must be submitted for authorization via the Provider Portal or faxed to the Prior Authorizations Department at 831-430-5850 (831-430-5515 for local referrals). For any questions, contact the Alliance Registered Dietitian at 831-430-5506.

Providers offering MNT to Alliance members should use the following codes for authorization and claims payment:

• CPT-4 Code 97802 - MNT, initial assessment and intervention, individual, face-to-face with patient, each 15 minutes.
• CPT-4 Code 97803 - MNT, re-assessment and intervention, individual, face-to-face with patient, each 15 minutes.
• CPT-4 Code 97804 - MNT, group (2 or more individuals), each 30 minutes.
• CPT-4-Code G0270 - MNT: 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.
• CPT-4-Code G0271 - MNT, 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), group (2 or more individuals), each 30 minutes.
• HCPC Code S9470 - Nutritional Counseling, dietitian visit, each 15 minutes.
• CPT-4 Code T1014 - Telehealth if applicable.

Annual MNT coverage is limited to a maximum of 3 hours for the first calendar year and 2 hours per calendar year in subsequent years. For additional MNT hours beyond the aforementioned utilization limits, a new authorization request with supporting documentation must be submitted to the Alliance for review.

Conditions include but are not limited to:

• Pediatric obesity with a BMI >95th percentile.
• Cancer with significant weight loss.
• Pre/post bariatric surgery.
• Conditions impairing digestion and absorption.
• Underweight status or unintended weight loss.

View the Medical Nutrition Therapy Quick Reference Guide for full details. For more information and a list of qualifying conditions on MNT, please see Policy 403-1149 – Medical Nutrition Therapy.

Enteral nutrition products and parenteral nutrition products that are billed as a pharmacy claim are transitioned from the Alliance pharmacy benefit to Medi-Cal Rx for Medi-Cal members. Enteral nutrition formulas, including nutrition support (tube feed) formulas, oral nutrition supplements and specialty infant formulas, can only be billed on a pharmacy claim. Refer to the List of Covered Enteral Nutrition Products on the Medi-Cal Rx website. Prior authorization requests for enteral nutrition products that are billed as a pharmacy claim must be submitted to Medi-Cal Rx. For more details about Medi-Cal Rx, refer to our Medi-Cal Pharmacy page.

For other enteral nutrition products and parenteral nutrition products that are billed as a medical claim, prior authorization is required to be submitted to the Alliance. Prior authorization requests can be submitted by the prescribing or servicing provider and may be submitted via the Provider Portal or faxed to the Prior Authorizations Department at 831-430-5506. A copy of the prescription and recent chart notes detailing the member’s diagnosis and medical necessity of the product being prescribed must be submitted. The criteria the Alliance uses to review authorization requests for medical necessity is outlined in Policy 403-1136 – Enteral Nutrition Products.

Please include the following when submitting a prior authorization:

• Copy of prescribing provider’s prescription.
• Completed prior authorization request form.
• Recent chart notes that address medical justification as to why the member is unable to meet his/her nutritional needs with standard or fortified foods.
• Growth charts for pediatric members or relevant weight history for adult members.