Home > For Providers > Manage Care > Pharmacy Services > Medical Nutrition Therapy Benefit Quick Reference Guide

Medical Nutrition Therapy Benefit Quick Reference Guide

Medical Nutrition Therapy (MNT) provided by a Registered Dietitian (RD) is a covered benefit for all lines of business for Alliance members that meet qualifying conditions or are deemed at nutritional risk.

Prior authorization is required for all MNT services. Prior authorizations can be requested through the Provider Portal by utilizing the following:

Authorization Class	Outpatient
Authorization Subclass	Rehab Therapies

Providers offering MNT to Alliance members should use the following codes for authorizations and claims payments:

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 individual[s]), 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

Annual MNT coverage is a maximum of 3 hours for the first calendar year and 2 hours per calendar year in subsequent years. For additional hours beyond these limitations, a new authorization request must be submitted for review.

Adults (>18 years) with a medical diagnosis deeming them to be “At Nutrition Risk” requiring a special or restrictive diet, including but not limited to:
Acute Renal Failure Allergic Gastroenteritis Cancer with Significant Weight Loss or Head, Neck, or Gastrointestinal in origin Celiac Disease Congestive Heart Failure Chronic Kidney Disease Chronic Non-Alcoholic Liver Disease Diabetes uncontrolled with 2 consecutive A1C values >9.0% Dysphagia Eating Disorders Gastrointestinal disease with malabsorption	Hepatic Disease Short Bowel Syndrome HIV/AIDS Significant Hyperlipidemia – Intolerance to statins OR LDL >190 and TG >500 Inborn Errors of Metabolism (i.e. PKU or galactosemia) Nutrition Support, i.e. Total Parenteral Nutrition, Enteral Nutrition Nutritional Anemia Obesity with BMI >40.0kg/m2 and two qualifying comorbidities Exception: BMI >30.0kg/m2 on a documented MD supervised weight loss plan with prescribed weight loss medication Pancreatitis Pre-Post Bariatric Surgery Poor Healing Wounds

Adults (>18 years) with a medical diagnosis deeming them to be “At Nutrition Risk” requiring a special or restrictive diet, including but not limited to:

Acute Renal Failure
Allergic Gastroenteritis
Cancer with Significant Weight Loss or Head, Neck, or Gastrointestinal in origin
Celiac Disease
Congestive Heart Failure
Chronic Kidney Disease
Chronic Non-Alcoholic Liver Disease
Diabetes uncontrolled with 2 consecutive A1C values >9.0%
Dysphagia
Eating Disorders
Gastrointestinal disease with malabsorption

Hepatic Disease
Short Bowel Syndrome
HIV/AIDS
Significant Hyperlipidemia – Intolerance to statins OR LDL >190 and TG >500
Inborn Errors of Metabolism (i.e. PKU or galactosemia)
Nutrition Support, i.e. Total Parenteral Nutrition, Enteral Nutrition
Nutritional Anemia
Obesity with BMI >40.0kg/m2 and two qualifying comorbidities
Exception: BMI >30.0kg/m2 on a documented MD supervised weight loss plan with prescribed weight loss medication
Pancreatitis
Pre-Post Bariatric Surgery
Poor Healing Wounds

Children (0-18 years) with a medical diagnosis deeming them to be “At Nutrition Risk” requiring a special or restrictive diet, including but not limited to:
Failure to thrive (BMI or weight for height < 10th percentile or a weight deceleration that crosses two major percentile lines on growth charts) Celiac Disease Chronic constipation	Dysphagia Eating Disorders/Disordered Eating with the exception of “picky eaters” Exception: Picky eaters must also have a diagnosis of autism spectrum disorder or be dependent on oral supplementation Food Allergies Hyperlipidemia Obesity BMI > 95th percentile Prediabetes

Supporting Programs

The Alliance offers a variety of culturally and linguistically programs to Alliance members at no charge. Please visit the Alliance Health Education and Disease Management page of the Alliance provider website for information. Providers and members may also call the Alliance Health Education Line at 800-700-3874, ext.5580 for more information.

Alliance Adult Weight Management Program – The program is available for adult members ages 18 years or older who are at-risk or diagnosed with obesity.

Healthy Weight for Life Program –The HWL program is available for parents or guardians of Alliance members ages 2-18 who are at-risk or diagnosed with childhood obesity. The program is offered in a 10-week workshop format for the parents or guardians. The workshops are delivered by Alliance Health Educators. Workshops are offered in multiple modalities to encourage access including sessions offered via virtual classes and in-person classes.

Live Better with Diabetes (LBD) Program – The LBD is a series of self-management workshops designed to help adult members diagnosed with diabetes. The LBD utilizes an evidence-based self-management program originally developed at Stanford University. The program is delivered as a 6-week workshop series. Workshops are offered in multiple modalities to encourage access including sessions offered via telephone calls, virtual classes and in-person classes.

Diabetes Prevention Program (DPP) –The Alliance covers a minimum of 22 hours of DPP sessions for the first 12 months of the DPP benefit and a second year comprised of eight (8) hour sessions (ongoing maintenance sessions) to promote maintenance, which is reserved for those individuals who have successfully completed the first year and have achieved and maintained their weight loss goal. The DPP is an evidence-based lifestyle change program, taught by peer coaches, designed to prevent or delay the onset of type 2 diabetes among individuals (ages 18 and older) diagnosed with prediabetes.

Healthier Living Program (HLP) – The HLP is a series of self-management workshops designed to help adult members diagnosed with chronic disease(s). The HLP utilizes an evidence-based self-management program originally developed at Stanford University. The program is delivered as a 6-week workshop series. Workshops are offered in multiple modalities to encourage access including sessions offered via telephone calls, virtual classes and in-person classes.