Nutrition and diet are important in the management of certain diseases, such as diabetes and renal disease. Proper diet and nutrition can help prevent and reduce complications from these conditions
Medical Nutrition Therapy (MNT) services provided by a registered dietitian or nutritionist may be considered medically necessary for members who have diabetes or renal disease, and after a transplant when referred by their doctor. For purposes of disease management, this includes the following:
The treating physician must prescribe these services and renew their referral yearly if continuing treatment is needed into another calendar year.
The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician.
Services may be provided either on an individual or group basis.
For a member with a diagnosis of diabetes, Diabetic Self-Management Training (DSMT) and MNT services can be provided within the same time period, and the maximum number of hours allowed under each benefit may be covered. The only exception is that DSMT and MNT may not be provided on the same day to the same member.
Medical Nutrition Therapy (MNT) services may be considered medically necessary according to the following parameters:
Additional hours of service are considered to be medically necessary and eligible if the treating physician determines that there is a change in the member’s condition, diagnosis, or treatment regimen that requires a change in MNT and orders additional hours during that episode of care.
Medical nutrition therapy provided for conditions other than those listed as eligible will be considered not medically necessary.
Payment for Dietitian and Nutritionist Services
Payment for a registered dietitian or nutrition professional services is made at the lesser of the actual charge or 85 percent of the physician fee schedule.
Medical nutrition therapy services including individual medical nutrition therapy delivered via an interactive telecommunications system may be covered when the guidelines listed on this policy are met.
97802 97803 97804 G0270 G0271
Diagnosis Codes Section
ICD-9 Diagnosis Codes
Covered Diagnosis Codes
249.00 249.01 249.10 249.11 249.20 249.21 249.30 249.31 249.40 249.41 249.50 249.51 249.60 249.61 249.70 249.71 249.80 249.81 249.90 249.91 250.00 250.01 250.02 250.03 250.10 250.11 250.12 250.13 250.20 250.21 250.22 250.23 250.30 250.31 250.32 250.33 250.40 250.41 250.42 250.43 250.50 250.51 250.52 250.53 250.60 250.61 250.62 250.63 250.70 250.71 250.72 250.73 250.80 250.81 250.82 250.83 250.90 250.91 250.92 250.93 403.01 403.11 403.91 404.02 404.03 404.12 404.13 404.92 404.93 583.89 585.1 585.2 585.3 585.4 585.5 588.1 593.9 646.20 646.21 646.22 646.23 646.24 648.00 648.01 648.01 648.02 648.03 648.04 648.80 648.81 648.82 648.83 648.84 V42.0 V65.3
ICD-10 Diagnosis Codes
Covered Diagnosis Codes
E08.00 E08.01 E08.10 E08.11 E08.22 E08.29 E08.3211 E08.3212 E08.3213 E08.3291 E08.3292 E08.3293 E08.3311 E08.3312 E08.3313 E08.3391 E08.3392 E08.3393 E08.3411 E08.3412 E08.3413 E08.3491 E08.3492 E08.3493 E08.3511 E08.3512 E08.3513 E08.3521 E08.3522 E08.3523 E08.3531 E08.3532 E08.3533 E08.3541 E08.3542 E08.3543 E08.3551 E08.3552 E08.3553 E08.3591 E08.3592 E08.3593 E08.37X1 E08.37X2 E08.37X3 E08.40 E08.41 E08.42 E08.43 E08.44 E08.49 E08.51 E08.52 E08.59 E08.610 E08.618 E08.620 E08.621 E08.622 E08.628 E08.630 E08.638 E08.641 E08.649 E08.69 E08.8 E08.9 E09.00 E09.01 E09.10 E09.11 E09.22 E09.29 E09.321 E09.3211 E09.3212 E09.3213 E09.329 E09.3291 E09.3292 E09.3293 E09.331 E09.3311 E09.3312 E09.3313 E09.339 E09.3391 E09.3392 E09.3393 E09.341 E09.3411 E09.3412 E09.3413 E09.349 E09.3491 E09.3492 E09.3493 E09.351 E09.3511 E09.3512 E09.3513 E09.3521 E09.3522 E09.3523 E09.3531 E09.3532 E09.3533 E09.3541 E09.3542 E09.3543 E09.3551 E09.3552 E09.3553 E09.359 E09.3591 E09.3592 E09.3593 E09.37X1 E09.37X2 E09.37X3 E09.40 E09.41 E09.42 E09.43 E09.44 E09.49 E09.51 E09.52 E09.59 E09.610 E09.618 E09.620 E09.621 E09.622 E09.628 E09.630 E09.638 E09.641 E09.649 E09.65 E09.69 E09.8 E09.9 E10.10 E10.11 E10.21 E10.22 E10.29 E10.3211 E10.3212 E10.3213 E10.3291 E10.3292 E10.3293 E10.3311 E10.3312 E10.3313 E10.3391 E10.3392 E10.3393 E10.3411 E10.3412 E10.3413 E10.3491 E10.3492 E10.3493 E10.3511 E10.3512 E10.3513 E10.3521 E10.3522 E10.3523 E10.3531 E10.3532 E10.3533 E10.3541 E10.3542 E10.3543 E10.3551 E10.3552 E10.3553 E10.3591 E10.3592 E10.3593 E10.37X1 E10.37X2 E10.37X3 E10.40 E10.41 E10.42 E10.43 E10.44 E10.49 E10.51 E10.52 E10.59 E10.610 E10.618 E10.620 E10.621 E10.622 E10.628 E10.630 E10.638 E10.641 E10.649 E10.65 E10.69 E10.8 E10.9 E11.00 E11.01 E11.21 E11.22 E11.29 E11.3211 E11.3212 E11.3213 E11.3291 E11.3292 E11.3293 E11.3311 E11.3312 E11.3313 E11.3391 E11.3392 E11.3393 E11.3411 E11.3412 E11.3413 E11.3491 E11.3492 E11.3493 E11.3511 E11.3512 E11.3513 E11.3521 E11.3522 E11.3523 E11.3531 E11.3532 E11.3533 E11.3541 E11.3542 E11.3543 E11.3551 E11.3552 E11.3553 E11.3591 E11.3592 E11.3593 E11.37X1 E11.37X2 E11.37X3 E11.40 E11.41 E11.42 E11.43 E11.44 E11.49 E11.51 E11.52 E11.59 E11.610 E11.618 E11.620 E11.621 E11.622 E11.628 E11.630 E11.638 E11.641 E11.649 E11.65 E11.69 E11.8 E11.9 E13.00 E13.01 E13.10 E13.11 E13.21 E13.22 E13.29 E13.3211 E13.3212 E13.3213 E13.3291 E13.3292 E13.3293 E13.3311 E13.3312 E13.3313 E13.3391 E13.3392 E13.3393 E13.3411 E13.3412 E13.3413 E13.3491 E13.3492 E13.3493 E13.3511 E13.3512 E13.3513 E13.3521 E13.3522 E13.3523 E13.3531 E13.3532 E13.3533 E13.3541 E13.3542 E13.3543 E13.3551 E13.3552 E13.3553 E13.3591 E13.3592 E13.3593 E13.37X1 E13.37X2 E13.37X3 E13.40 E13.41 E13.42 E13.43 E13.44 E13.49 E13.51 E13.52 E13.59 E13.610 E13.618 E13.620 E13.621 E13.622 E13.628 E13.630 E13.638 E13.641 E13.649 E13.65 E13.69 E13.8 E13.9 I12.9 N18.1 N18.2 N18.3 N18.4 N18.5 O24.011 O24.012 O24.013 O24.03 O24.111 O24.112 O24.113 O24.13 O24.410 O24.414 O24.415 O24.419 O24.420 O24.424 O24.425 O24.429 O24.430 O24.434 O24.435 O24.439 O24.811 O24.812 O24.813 O24.83 Z48.22
Refer to Medicare Advantage medical policy N-15 for information on Diabetic Self-Management Training (DSMT).
Refer to Medicare Advantage medical policy N-60 for information on Telemedicine/Telehealth Services.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
