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 Atherosclerosis – including Coronary Artery Disease and Peripheral Artery Disease 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 with an A1C value >7% Dysphagia Eating Disorders Gastrointestinal disease with malabsorption Gestational Diabetes or impaired glucose during pregnancy	Hepatic Disease, Fatty Liver (NASH, NAFLD) Short Bowel Syndrome HIV/AIDS Hyperlipidemia – Intolerance to statins OR LDL >150 and TG >200 Inborn Errors of Metabolism (i.e. PKU or galactosemia) Metabolic Disease Nutrition Support, i.e. Total Parenteral Nutrition, Enteral Nutrition Nutritional Anemia Obesity with BMI >30kg/m2 and one comorbidity or BMI >40kg/m2 Exception: BMI >30.0kg/m2 on a prescribed weight loss medication Pancreatitis Polycystic Ovarian Syndrome (PCOS) 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
Atherosclerosis – including Coronary Artery Disease and Peripheral Artery Disease
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 with an A1C value >7%
Dysphagia
Eating Disorders
Gastrointestinal disease with malabsorption
Gestational Diabetes or impaired glucose during pregnancy

Hepatic Disease, Fatty Liver (NASH, NAFLD)
Short Bowel Syndrome
HIV/AIDS
Hyperlipidemia – Intolerance to statins OR LDL >150 and TG >200
Inborn Errors of Metabolism (i.e. PKU or galactosemia)
Metabolic Disease
Nutrition Support, i.e. Total Parenteral Nutrition, Enteral Nutrition
Nutritional Anemia
Obesity with BMI >30kg/m2 and one comorbidity or BMI >40kg/m2
Exception: BMI >30.0kg/m2 on a prescribed weight loss medication
Pancreatitis
Polycystic Ovarian Syndrome (PCOS)
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 Diabetes Type 1 and Type 2	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 or Formula intolerance Hyperlipidemia Obesity BMI > 95th percentile Prediabetes

Supporting Programs

The Alliance offers a variety of health and disease management programs to Alliance members at no cost. 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.