Nutritional Counseling
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Defines when Aetna considers nutritional counseling medically necessary, investigational, or excluded, and lists covered CPT/HCPCS/ICD-10 codes and clinical contexts; applies to plan-recognized providers delivering nutrition services.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Medically necessary indications
Covered when ALL of the following are met
Provider must be recognized under the member's plan and some plans may require a referral; counselor functions as a consultant coordinating care with the referring physician.
Reflects USPSTF screening and referral recommendations for obesity and CVD risk.
inv-02: Experimental, investigational, or unproven services
Not covered / experimental
NutrEval has no specific CPT code; use is considered investigational.
These indications are listed as not covered for the purposes described in this policy.
Nutritional counseling and testing described in this bulletin are considered unproven for indications that lack evidence of a nutritional relationship to the condition. Specifically, the policy lists counseling for conditions such as asthma, attention‑deficit hyperactivity disorder (ADHD), and chronic fatigue syndrome as examples of indications that are considered of unproven value and may be denied. The document also identifies NutrEval — a comprehensive functional/nutritional assessment with no specific CPT code — as experimental/investigational for the indications discussed and therefore not covered.
This Clinical Policy Bulletin is intended as a general summary to assist in administering plan benefits. It is not a contract and does not guarantee coverage for any specific service. Coverage determinations may vary by plan and are governed by the member’s benefit provisions and plan‑specific documentation; providers should consult plan requirements and Clinical Policy Unit notes for any prior authorization or coverage details.
Nutritional counseling for conditions not shown to be nutritionally related — for example, asthma, ADHD, and chronic fatigue syndrome — is considered of unproven value and is therefore not medically necessary for those indications under this bulletin.
Coding
| 90951 | ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month. |
| 90952 | ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month. |
| 90953 | ESRD related services monthly, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month. |
| 90954 | End-stage renal disease (ESRD) related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month. |
| 90955 | ESRD related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month. |
| 90956 | ESRD related services monthly, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month. |
| 90957 | End-stage renal disease (ESRD) related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 4 or more face-to-face physician visits per month. |
| 90958 | ESRD related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 2-3 face-to-face physician visits per month. |
| 90959 | ESRD related services monthly, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents; with 1 face-to-face physician visit per month. |
| 90963 | End-stage renal disease (ESRD) related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents. |
| NutrEval | No specific CPT code; functional/nutritional assessment testing considered experimental/investigational. |
| E66.01 - E66.2, E66.8 - E66.9 | Obesity. |
| E66.3 | Overweight (covered for adults who are overweight, BMI greater than 25.0 kg/m2 and have other cardiovascular disease risk factors). |
| F50.00 - F50.9 | Eating disorders. |
| Z68.25 - Z68.29 | Body mass index (BMI) adult, 25.0 – 29.9 kg/m2 (covered for adults who have other cardiovascular disease risk factors). |
| Z68.30 - Z68.45 | Body mass index (BMI) adult, 30.0 – 40+ kg/m2. |
| Z68.53 | Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age. |
| Z68.54 | Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age. |
| F90.0 - F90.9 | Attention-deficit hyperactivity disorder (listed as not covered for indications in the CPB). |
| J45.20 - J45.909 | Asthma (listed as not covered for indications in the CPB). |
| R53.82 | Chronic fatigue, unspecified (chronic fatigue syndrome NOS) (listed as not covered). |
Provider Actions & Operational Notes
Provider responsibilities and referral coordination
Covered codes are allowed when medical necessity criteria are met and services are furnished by plan-recognized providers. Counselors function primarily in a consultative role to evaluate the member and coordinate ongoing care with the referring physician; treating providers remain responsible for medical advice and treatment. Some plans require a referral for nutritional counseling — verify member benefit plan requirements prior to scheduling.
- Covered when medical necessity criteria are met and services furnished by a plan-recognized provider (e.g., licensed nutritionist, registered dietitian, or other qualified licensed health professional).
- Counselor acts as consultant and coordinates care with the referring physician.
- Some plans require referrals — check benefit plan descriptions.
Potential denials for unproven indications
Services for conditions that have not been shown to be nutritionally related may be denied as unproven. Examples of conditions for which nutritional counseling is considered of unproven value include asthma, attention-deficit hyperactivity disorder, and chronic fatigue syndrome. The use of certain tests (e.g., NutrEval) that provide comprehensive functional and nutritional assessment is considered experimental and investigational and may be denied.
- Potential denial for indications not shown to be nutritionally related (examples: asthma, ADHD, chronic fatigue syndrome).
- NutrEval and similar comprehensive functional/nutritional allergy tests are considered experimental/investigational and are not covered.
Coverage disclaimer and prior authorization guidance
Clinical Policy Bulletins are informational and provide a partial description of plan benefits; they do not constitute a contract. Participating providers are independent contractors; treating providers are responsible for medical advice and treatment. Verify prior authorization and referral requirements with the plan or benefit booklet as this bulletin does not specify operational prior authorization rules.
- CPBs are informational and do not replace benefit plan documents or contracts.
- Providers are responsible for medical advice and treatment; participating providers are independent contractors.
- This bulletin does not state specific prior authorization requirements — check plan/prior authorization resources.
Background
Medical nutrition therapy consists of an assessment of a person’s overall nutritional status followed by an individualized diet plan, counseling, and, when appropriate, specialized nutrition therapies provided by qualified professionals such as registered dietitians. It is used as part of the therapeutic approach for multiple chronic conditions — including diabetes, cardiovascular disease, hypertension, kidney disease, eating and gastrointestinal disorders, seizure disorders (e.g., ketogenic diet), and chronic pulmonary disease — where dietary modification has a recognized role in management.
Definitions
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