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| Medical Policy: | V-44-015 |
| Topic: | Medical Nutrition Management Services (MNT) |
| Section: | Visits |
| Effective Date: | October 1, 2016 |
| Issue Date: | February 27, 2017 |
| Last Reviewed: | February 2017 |
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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 circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Medical nutrition therapy (MNT) is covered for certain conditions listed below. This list includes those diagnoses/conditions that most commonly benefit from MNT in improving desired health outcomes. (This is not intended to be an all-inclusive list.)
- Human immunodeficiency virus (HIV) disease
- Secondary diabetes mellitus
- Diabetes mellitus
- Nutritional deficiencies
- Disorders of amino-acid transport and metabolism
- Disorders of lipid metabolism
- Disorders of mineral and calcium metabolism
- Hyponatremia
- Hyperpotassemia
- Hypopotassemia
- Cystic fibrosis
- Other specified disorders of metabolism
- Morbid obesity
- Anorexia nervosa and eating disorders
- Epilepsy and other convulsive disorder
- Hypertensive disease
- Ischemic heart disease
- Chronic pulmonary heart disease
- Cardiomyopathy
- Heart failure
- Myocarditis
- Myocardial degeneration
- Cardiovascular disease
- Cardiomegaly
- Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and duodenitis
- Disorders of function of stomach and gastrostomy complications and other disorders of stomach and duodenum
- Regional enteritis, ulcerative colitis, vascular insufficiency of intestine, other and unspecified noninfectious gastroenteritis and colitis, intestinal obstruction, diverticula of intestine, and functional digestive disorders
- Colostomy and enterostomy complications, and other specified disorders of the intestines
- Liver diseases, cirrhosis, and other diseases of the digestive system
- Glomerulonephritis, nephrotic syndrome, nephritis, renal failure, infections of kidney, calculus of kidney and ureter, and disorder of bladder
- Hypertension complicating pregnancy, childbirth, and the puerperium
- Gestational diabetes
- Osteoporosis
- Congenital anomalies of the digestive system
- Congenital anomalies of kidney
- Symptoms concerning nutrition, metabolism and development
Medical nutrition therapy may also be covered for the management of obesity per the member's group or individual benefit program.
Preventive medicine counseling, for patients with risk factors for diet related chronic diseases, is covered for the following:
- Dietary surveillance and counseling; and
- mixed hyperlipidemia, or
- other and unspecified hyperlipidemia.
When reported separately, charges for medical nutrition therapy should be combined with and processed under the appropriate medical visit procedure codes. If MNT is the only service performed, it will be reimbursed in accordance with the member's medical care benefits. Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.
When the 25 modifier is reported, the patient's records must clearly document that separately identifiable medical care has been rendered.
See Medical Policy Bulletin Z-27 for information on Eligible Providers and Supervision Guidelines. See Medical Policy Bulletin G-24 for information on the Treatment of Obesity. See Medical Policy Bulletin E-15 for information on Diabetic Services and Supplies. See Medical Policy Bulletin V-37 for information on Autism Spectrum Disorders. |
| Place of Service: Inpatient/Outpatient |
Medical Nutrition Therapy (MNT) is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
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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 circumstances may warrant individual consideration, based on review of applicable medical records.
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:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
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.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
