CurrentmhnPolicy N/A

Authorization Guide for Medically Tailored Meals / Medically Supportive Food

Defines authorization, eligibility, documentation, coding, and provider requirements for covering up to two medically tailored meals per day or a weekly grocery box for members with nutrition-sensitive chronic or serious health conditions.

Policy Summary

Payermhn

PolicyAuthorization Guide for Medically Tailored Meals / Medically Supportive Food

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit CS Referral Form with a nutrition assessment by an RDN or appropriate clinician and a provider order specifying the nutrition-sensitive condition with the authorization request.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 2/dayservice limit per member

12 wksinitial auth duration

S5170,S9470,S9977billing codes listed

nutrition assessment & ordercore documentation required

Coverage Criteria

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Initial coverage criteria

Covered when ALL of the following are met

Member condition: Member has a chronic or other serious nutrition-sensitive health condition (examples include but are not limited to: cancer, cardiovascular disorders, chronic kidney disease, chronic lung disorders including asthma/COPD, chronic or disabling mental/behavioral health disorders, diabetes or other metabolic conditions, dyslipidemia, elevated lead levels, end-stage renal disease, fatty liver, gastrointestinal disorders, heart failure, high cholesterol, high-risk perinatal conditions, HIV, hypertension, liver disease, malnutrition)

examples listed in document

Clinical documentation: Nutrition assessment by a registered dietitian or other appropriate clinician that documents the nutrition-sensitive condition, member nutritional needs, and includes the meal plan and standards prior to the meal request; plus a provider order from an authorized clinician (e.g., physician, RD, CNS, NP, pharmacist, PA) specifying the nutrition-sensitive condition. The nutrition assessment and provider order must be submitted with the authorization request.

Assessment and provider order required

Service parameters: Service is limited to up to two meals per day or a weekly grocery box for up to 12 weeks; a member may receive only one meal type at a time (prepared meal or grocery box); a change of meal type requires a new authorization request.duration <= 12 weeks unless extended

Extension requires a new authorization with supporting documentation demonstrating ongoing medical or nutritional need

Services are excluded when they duplicate existing programs or funding sources or when they are intended only to address food insecurity rather than an identified clinical need. Specifically, members who are already enrolled in a duplicative nutrition or medically supportive food program are not eligible for these services. Meals that are eligible for or reimbursed by another food program should be avoided. Additionally, initial authorization limits may only be exceeded with a new authorization request and supporting clinical documentation demonstrating ongoing medical or nutritional need.

Services provided solely to address food insecurity, without an associated clinical nutrition-sensitive condition, are not eligible for coverage. Authorization requires documentation of clinical need; meals that exist only to respond to food insecurity (and not as part of clinical care for a qualifying condition) must be denied or excluded.

Coding and Billing

Covered HCPCS CodesHCPCSCovered

S5170	home delivered prepared meal, U6
S9470	nutritional counseling, diet, U6
S9977	per weekly grocery box, delivered, U6

Nutrient coverage requirement

RequirementMedically tailored meals or groceries must meet at least two-thirds of the daily nutrient and energy needs of an average individual.

Assessment basisTwo-thirds threshold is to be estimated by the RDN/clinician overseeing the design of the MTM/MTG services.

Dietary impact’Medically tailored’ interventions must be provided in specified quantities to constitute the majority of the member's diet over the course of the intervention.

ApplicabilityApplies to both prepared meals and grocery box (MTM/MTG) services included in this program.

Provider Actions & Authorization

Prior Authorization

Authorization requirements — initial and extensions

Initial authorization: Up to two meals per day or a weekly grocery box, for up to 12 weeks. A member may receive only one meal type at a time (prepared meal or grocery box); changing meal type requires a new authorization request. If a medically necessary extension is needed, submit a new authorization request with a current nutrition assessment and provider order. The initial authorization limit may be exceeded only with supporting clinical documentation (e.g., medical notes) demonstrating ongoing medical and/or nutritional need for additional services.

Initial authorization: ≤ 2 meals/day OR 1 weekly grocery box, up to 12 weeks
Member may receive only one meal type at a time (prepared meal S5170 or grocery box S9977) — changing type requires new authorization
Authorization extension requires new request + current nutrition assessment + provider order; exceed initial limits only with supporting clinical documentation

Step Therapy

Step-down from MTM to MSF

Medically Supportive Food (MSF) is intended as a step-down intervention from Medically Tailored Meals (MTM) when clinically appropriate. MSF services must be overseen and signed off by a registered dietitian nutritionist (RDN) or other appropriate clinician, and meet the same oversight/signing requirements described for MTM.

MSF is a step-down from MTM and is supplemental to a member’s diet
MSF oversight/sign-off required from RDN or appropriate clinician

Documentation Required

Required documentation — referral, assessment, and provider order

Required documentation must be submitted with the authorization request. Include a completed CS Referral Form and the items below: a nutrition assessment performed by an RDN or other appropriate clinician that documents the member’s nutrition-sensitive condition, the meal plan and standards prior to the meal request; and a provider order from a licensed healthcare provider or other appropriate clinician (e.g., physician, RD, CNS, NP, pharmacist, PA) specifying the nutrition-sensitive condition. Members must have chronic or other serious nutrition-sensitive health conditions (examples: cancer, cardiovascular disorders, chronic kidney disease, chronic lung disorders including asthma/COPD, chronic or disabling mental/behavioral health disorders, diabetes, dyslipidemia, end-stage renal disease, fatty liver, gastrointestinal disorders, heart failure, hypertension, HIV, malnutrition, and high-risk perinatal conditions).

CS Referral Form with supporting documentation
Nutrition assessment by RDN or appropriate clinician including meal plan/standards
Provider order specifying the nutrition-sensitive condition (physician, RD, CNS, NP, pharmacist, PA, or equivalent)
Documentation of qualifying nutrition-sensitive chronic/serious health condition (see examples)

Definitions

Medically tailored meals (MTM)

DefinitionPrepared meals designed as part of clinical care to meet at least two-thirds of the daily nutrient and energy needs and to constitute the majority of the member's diet during the intervention.

PurposeTo address members' chronic or serious nutrition-sensitive health conditions as part of clinical care (not solely to address food insecurity).

Service limitsCovered up to two meals per day or a weekly grocery box for up to 12 weeks; member may receive only one meal type at a time.

Provider oversightDesign and nutrient estimation must be overseen by a registered dietitian nutritionist (RDN) or appropriate clinician.

Medically supportive food (MSF)

DefinitionSupplemental food packages intended as step-down interventions that adhere to national nutrition guidelines and are overseen and signed off by an RDN or appropriate clinician.

Role in careOffered as a step-down intervention from medically tailored meals where appropriate; intended to be supplemental to a member's diet.

StandardsMSF packages must adhere to national nutrition guidelines to prevent, manage, or reverse nutrition-sensitive conditions.

Oversight requirementMSF services must be overseen and signed off on by an RDN or another appropriate clinician.

OpenPayer

Authorization Guide for Medically Tailored Meals / Medically Supportive Food

Coverage Criteria

Coding and Billing

Provider Actions & Authorization

Background

Definitions