CurrenteoccoPolicy N/A

Medical Nutrition Therapy Coverage Criteria

Customize your policy alerts

Sign up for all eocco policy alerts

Know when eocco releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines coverage and medical necessity criteria for medical nutrition therapy (MNT) by registered dietitians for prevention and treatment of obesity, eating disorders, and failure to thrive for Moda/Eocco members.

Policy Summary

Payereocco

PolicyMedical Nutrition Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJun 24, 2026

Next Review DateJun 24, 2026

Key ActionSubmit required documentation with prior authorization requests for CPT codes 97802, 97803, 97804.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97802-04CPT/HCPCS procedure codes covered

Age 6-17Covered (children)

Age 18+Covered (adults)

F50.xEating disorder codes

CDC percentiles

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrenteoccoPolicy N/A

Medical Nutrition Therapy Coverage Criteria

Customize your policy alerts

Sign up for all eocco policy alerts

Know when eocco releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

Payereocco

PolicyMedical Nutrition Therapy Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJun 24, 2026

Next Review DateJun 24, 2026

Key ActionSubmit required documentation with prior authorization requests for CPT codes 97802, 97803, 97804.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97802-04CPT/HCPCS procedure codes covered

Age 6-17Covered (children)

Age 18+Covered (adults)

F50.xEating disorder codes

CDC percentiles

Coverage and Medical Necessity Criteria

Pediatric Preventive Service (Children age 6-17)

Covered when ALL of the following are met

Pediatric overweight/obese coverage: Member is age 6-17 AND has BMI-for-age at or above the 85th percentile (overweight) OR at or above the 95th percentile (obese) per CDC growth chartsBMI percentile thresholds per CDC

Comprehensive, intensive behavioral intervention delivered as medical nutrition therapy (MNT) is considered a medically necessary preventive service for this population.

Adult Preventive Service (Adults 18+)

Covered when ANY of the following adult criteria are met

Adult obesity coverage: Member is age 18 or older AND has BMI >= 30 kg/m2 (obese)BMI >=30 kg/m2

Intensive, multicomponent behavioral interventions delivered as medical nutrition therapy (MNT) are medically necessary for adults meeting this criterion.

Adult overweight with CVD risk factors: Member is age 18 or older AND has BMI 25-29.9 kg/m2 (overweight) AND has one or more cardiovascular disease (CVD) risk factors: hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndromeBMI 25-29.9 kg/m2 plus listed CVD risk factors

MNT with intensive behavioral counseling is medically necessary for these adults.

Failure to Thrive (Underweight) Coverage

Covered when ALL of the following are met

Failure to thrive: Member has BMI under 18.5 (underweight) AND a diagnosis of failure to thrive AND a prescription by a physician or qualified provider for medical nutrition therapy (e.g., licensed nutritionist, registered dietitian, or other qualified licensed health professional)BMI <18.5

Comprehensive behavioral interventions via MNT are medically necessary when all conditions are present.

Eating Disorders

Covered when ANY of the following diagnoses are present

Eating disorder diagnoses: Member has one of the specified ICD-10 eating disorder diagnoses: F50.00, F50.01, F50.02, F50.2, F50.8, F50.81, F50.82, F50.89, or F50.9ICD-10 F50.x

Requests for coverage of MNT for eating disorders should be submitted to Moda Behavioral Health for review.

The policy includes a section titled "CPT or HCPC codes NOT covered," but no specific CPT or HCPCS codes are listed as not covered in the document.

This document does not identify any explicit conditions or services that are designated as "not medically necessary." No entries are listed under a not-medically-necessary section in the current policy.

Billing and Diagnosis Codes

Covered CPT CodesCPTCovered

97802	Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
97803	Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
97804	Medical nutrition therapy; group (2 or more individuals), each 30 minutes.

Applicable ICD-10 Diagnosis Codes (Eating Disorders)ICD-10Covered

F50.00	Anorexia Nervosa, Unspecified
F50.01	Anorexia Nervosa, Restricting Type
F50.02	Anorexia nervosa, Binge-eating/Purging Type
F50.2	Bulimia Nervosa
F50.8	Other Eating Disorders
F50.81	Binge Eating Disorders
F50.82	Avoidant/Restrictive Eating Disorder
F50.89	Other Specified Eating Disorder
F50.9	Eating Disorder, Unspecified

Appendix Diagnosis CodesICD-10

No codes listed

BMI percentiles / thresholds — summary

Children (BMI-for-age percentiles)Overweight: BMI >=85th to <95th percentile; Obese: BMI >=95th percentile (per CDC BMI-for-age growth charts)

Adults (BMI kg/m2)Obese: BMI >=30 kg/m2; Overweight: BMI 25–29.9 kg/m2 (additional CVD risk factors required for coverage)

Underweight (Failure to thrive) thresholdBMI <18.5 kg/m2 plus diagnosis of failure to thrive and physician/provider prescription for MNT

CDC referenceUse CDC growth charts for children/teens to determine BMI-for-age percentiles

Provider Billing, Authorization, and Documentation

Prior Authorization

Prior authorization required for MNT CPT codes

Prior authorization is required for MNT services billed with CPT codes 97802, 97803, and 97804; prior authorization requests must include the required documentation listed below for coverage determination.

Covered CPT codes: 97802, 97803, 97804
Include documentation described in the “Information Submitted with the Prior Authorization Request” section

Note

Documentation Required

Required documentation to submit with PA

Submit one of the following with the prior authorization request: documentation of obesity screening/treatment; medical record documentation of failure to thrive (which may include history and physical exam, observation of parent‑child interactions, documentation of feeding patterns, and home visit notes); or documentation of an eating disorder diagnosis.

Background and Rationale

Medical nutrition therapy (MNT) is an individualized assessment and treatment provided by a registered dietitian and integrated into care for chronic diseases and conditions such as cardiovascular disease, diabetes, hypertension, kidney disease, eating and gastrointestinal disorders, and seizure disorders. The policy aligns MNT with preventive and therapeutic services recommended by clinical guidance, including obesity screening and referral for intensive, multicomponent behavioral interventions when members meet specified BMI criteria.USPSTF-recommended screening for obesity supports identification of children and adults who may benefit from referral to MNT.

Key Definitions

Child/Adolescent BMI categories (CDC)

Overweight (children/adolescents)BMI at or above the 85th percentile and below the 95th percentile for age and sex (CDC)

Obese (children/adolescents)BMI at or above the 95th percentile for age and sex (CDC)

Underweight (children/adolescents)BMI less than the 5th percentile for age and sex (CDC reference table)

Adult BMI categories

Obesity (adults)BMI greater than or equal to 30 kg/m2

Overweight (adults)BMI 25–29.9 kg/m2 (coverage for MNT requires one or more CVD risk factors: hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome)