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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.

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

The Alliance does not approve MNT for diagnoses of diabetes or prediabetes without a qualifying comorbidity. All eligible members with a diagnosis of diabetes or prediabetes are eligible to access comprehensive individual and group education through an Alliance-approved education provider. The Alliance offers Diabetes Self- Management Education (DSME) and the Diabetes Prevention Program (DPP). Some Alliance-approved education providers may have age restrictions and members with other health coverage must utilize all benefits provided through their primary insurer before utilizing Alliance benefits.

The Alliance does not cover MNT for adult weight management with a diagnosis of obesity without a qualifying comorbidity. Members ages 18 and older that have a diagnosis of obesity and have a BMI of 30 or above are eligible for the Alliance Wellness that Works Support Program (WWSP). The WWSP is a one-time benefit and only available for members who have Alliance as a primary insurance.

The Alliance also offers a Healthier Living program (HLP) which is a six-week series of self-management workshops that focus on health, wellness, and problems, that are common to individuals suffering from any chronic conditions

For further information regarding these programs please call the Alliance Health Education line 800-700-3874 ext. 5580.