Medical Nutrition Therapy (MNT) Coverage Criteria
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Governance of coverage, prior authorization, provider qualifications, and documentation requirements for Medical Nutrition Therapy (MNT) for HUSKY Health (Connecticut Medicaid) members.
Coverage of MNT is limited to three (3) hours per calendar year with an additional three (3) hours considered medically necessary under specified criteria for a maximum of six (6) hours per calendar year.
Prior authorization is required for MNT services beyond the initial three (3) hours per calendar year.
MNT must be provided by a CMAP-enrolled, CT DPH-certified dietitian-nutritionist and ordered by a CMAP-enrolled physician or licensed practitioner.
Coverage and Medical Necessity Criteria
Criteria for Additional MNT Hours (beyond initial 3 hours)
An additional three (3) hours (for a maximum of six (6) hours total) per calendar year of MNT services (CPT Codes 97803, 97804) may be considered medically necessary when ALL of the following are met:
Licensed practitioners include APRN, CNM, PA.
MNT services are limited to diagnoses listed on Table 26: List of Diagnosis Codes for MNT Services on the DSS Fee Schedule Instructions. MNT provided for conditions other than those listed on Table 26 is identified in the policy as not meeting medical necessity criteria and is not eligible for coverage.
Medical Nutrition Therapy for diagnoses not included on Table 26 of the DSS Fee Schedule Instructions is considered not medically necessary and therefore not covered under this policy.
Billing Codes and Annual Limits
| 97802 | Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes |
| 97803 | Medical nutrition therapy; reassessment and intervention, individual, face-to-face with the patient, each 15 minutes |
| 97804 | Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes |
Prior Authorization, Documentation, and Provider Requirements
PA required for additional MNT hours
Prior authorization is required for MNT services beyond the initial three (3) hours per calendar year, typically when requesting additional units billed with CPT codes 97803 and 97804.
- Applies when requesting additional MNT hours beyond the initial 3-hour annual allowance.
This policy document header contains provider policies and procedures applicable to HUSKY Health (Connecticut Medicaid) and frames the requirements in this section.
Required Documentation for PA
Submit a complete prior authorization package including the MNT-specific PA form, recent referral/order, plan of care, prior visit notes, and a signed clinical note from the certified dietitian‑nutritionist.
- Fully completed authorization request via fax
- Fully completed Medical Nutrition Therapy Services Prior Authorization Request Form
- Referral/order from a CMAP‑enrolled physician or other licensed practitioner written within the past 3 months
- Plan of care with measurable short- and long-term goals and interventions
- Notes from all previous visits documenting interventions performed and patient response
- Signed and dated clinical note from the certified dietitian‑nutritionist supporting medical necessity
Prior Authorization Requirement and denial risk
Requests for MNT beyond the initial three (3) hours per calendar year require prior authorization; failure to provide the required documentation may result in denial of the request.
- Coverage determinations are based on review of submitted case‑specific information.
Diagnosis Restriction — Table 26 required
MNT for diagnoses not listed on Table 26: List of Diagnosis Codes for MNT Services on the DSS Fee Schedule Instructions is considered not medically necessary and may be denied.
Definitions and Special Provisions
Background
Medical Nutrition Therapy (MNT) is a treatment modality using nutrition-focused assessment, education, and behavioral counseling to prevent or manage medical conditions. This policy follows the DSS Fee Schedule Instructions in defining eligible diagnoses; services for diagnoses outside Table 26 are classified as not medically necessary and may be denied.
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