CurrentmhnPolicy N/A

Medically Tailored Meals / Medically Supportive Food authorization

Governs authorization, coverage criteria, documentation, and billing for medically tailored meals, medically supportive food (grocery boxes), and associated nutrition education for members with nutrition-sensitive chronic or serious health conditions in the payer's jurisdiction.

Policy Summary

Payermhn

PolicyMedically Tailored Meals / Medically Supportive Food authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain a provider order and nutrition assessment by an RDN or appropriate clinician and submit prior authorization for up to two meals/day or a weekly grocery box for up to 12 weeks.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

up to 2/dayinitial authorization limit

12 weeksauthorization duration

>= 2/3 dailynutrient/energy requirement

one at a timemeal type restriction

Coverage criteria for medically tailored meals and supportive food

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Initial coverage criteria

Covered when ALL of the following are met

Eligibility and clinical need: Member has chronic or other serious nutrition-sensitive health condition (examples include 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; obesity).

examples listed in document

Provider order and assessment: Provider order from a licensed healthcare provider or other appropriate clinician (examples: physician, registered dietitian (RD), clinical nurse specialist (CNS), nurse practitioner (NP), pharmacist, or physician assistant (PA)) specifying the nutrition-sensitive condition, plus a nutrition assessment by a registered dietitian or other appropriate clinician that includes the meal plan and standards prior to the meal request.

provider types listed in document

Intervention characteristics: Service provided as part of the member's clinical care (not intended to respond solely to food insecurity); medically tailored meals or medically supportive groceries must meet at least two-thirds of daily nutrient and energy needs; medically supportive foods are intended as a step-down intervention from medically tailored meals when appropriate; member may receive either prepared meals or a weekly grocery box, and only one meal type at a time.>= two-thirds of daily nutrient and energy needs

MTM intended to constitute majority of diet during intervention; MSF are supplemental/step-down

Authorization limits: Initial authorization limited to up to two meals per day or a weekly grocery box for up to 12 weeks; extensions require a new authorization request plus a nutritional assessment and provider order or other supporting clinical documentation demonstrating ongoing medical or nutritional need.

initial limits can be exceeded with supporting clinical documentation

Services are excluded when they duplicate existing nutrition programs or other medically supportive food benefits. Specifically, a member who is already participating in a duplicative nutrition or medically supportive food program will not be eligible for coverage under this service, and meals that are eligible for or reimbursed by another food program are excluded. These exclusions ensure the program supplements clinical care rather than replacing or duplicating existing benefits.

Additionally, coverage will not be provided when the primary purpose of the request is to address food insecurity alone. Interventions must be integrated into clinical care and tied to a nutrition-sensitive medical indication to qualify.

Requests submitted solely to address food insecurity without an accompanying nutrition-sensitive clinical indication are not eligible for coverage. The service is intended to support management of chronic or serious nutrition-sensitive health conditions and must be ordered and documented as part of clinical care.

Billing and coding

Allowed service codesHCPCSCovered

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

inv-05: Nutrient/Energy sufficiency — meals must meet >= two-thirds of daily nutrient and energy needs

RequirementMeals must meet at least two-thirds (>= 2/3) of an average individual's daily nutrient and energy needs as estimated by the RDN/clinician overseeing the service.

Application Applies to both medically tailored meals and medically tailored groceries when provided singularly or in combination to constitute the majority of the member's diet during the intervention.

Assessment basisRDN or appropriate clinician must estimate the two-thirds daily need and oversee design of MTM/MTG services.

Role in coverageMeeting this nutrient/energy sufficiency is a required element of the coverage criteria for MTM/MSF services.

Provider authorization, documentation, and operational requirements

Prior Authorization

Prior Authorization Required

Initial authorization: Up to two meals per day or one weekly grocery box for a maximum of 12 weeks. Extensions: If ongoing services are medically necessary beyond the initial authorization, submit a new authorization request that includes a current nutritional assessment and a provider order. The initial 12‑week limit may be exceeded only when supporting clinical documentation (for example, medical notes) demonstrates continued medical necessity based on the member's nutrition-sensitive health condition and nutritional needs.

Initial authorization: ≤ 2 meals/day OR 1 weekly grocery box, up to 12 weeks
Extension requires: new authorization request + current nutritional assessment + provider order
Exception to initial limit: may exceed 12 weeks only with supporting clinical documentation demonstrating medical necessity

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 authorized by an RDN or other appropriate clinician and documented in the member's plan of care. Transitioning from MTM to MSF should be supported by the member's nutrition assessment and provider order, and the authorization must reflect the change in service type and goals (supplemental/supportive rather than full-meal replacement).

MSF is a step-down intervention from MTM
MSF must be overseen/signed off by an RDN or appropriate clinician
Authorization must document the step-down and be supported by nutrition assessment and provider order

Denial Risk

Denial triggers include requests that duplicate other nutrition or medically supportive food programs, requests that are solely for food insecurity without documented medical necessity, or services that are eligible for reimbursement under another food program. Documentation supporting medical necessity must accompany authorization and extension requests; absence of required clinical documentation may result in denial.

Duplicative program participation may lead to denial
Requests motivated solely by food insecurity without clinical need will be denied
Services reimbursable by another food program are not eligible

Documentation Required

Documentation Requirements

Required documentation for initial authorization and extensions includes: a completed CS Referral Form with supporting documentation; a nutrition assessment performed by an RDN or other appropriate clinician that documents the member's nutrition-sensitive condition and the proposed meal plan/standards; and a provider order from a licensed health care provider or other appropriate clinician specifying the nutrition-sensitive condition. For extensions, include updated clinical notes or other evidence supporting continued medical necessity.

CS Referral Form with supporting documentation
Nutrition assessment by RDN or appropriate clinician (includes meal plan and standards)
Provider order specifying the nutrition-sensitive condition (licensed clinician: physician, RD, NP, PA, CNS, pharmacist, etc.)
For extensions: updated clinical documentation demonstrating ongoing medical necessity

Background and intent

Medically tailored meals and medically supportive food are intended to address nutrition-sensitive chronic or serious health conditions and must be provided as part of clinical care rather than solely to address food insecurity. The program aims to improve clinical outcomes by supplying substantial portions of a member’s nutritional needs and integrating meal or grocery interventions with provider orders and nutrition assessments.

Initial authorizations permit interventions up to defined limits, and extensions require submission of a new authorization request plus a nutritional assessment and provider order. When ongoing medical or nutritional need is demonstrated with supporting clinical documentation, initial authorization limits may be exceeded.

Key definitions

inv-11: Medically tailored meals (MTM) — prepared meals meeting >= two-thirds of daily nutrient/energy needs and integrated into clinical care

DefinitionPrepared meals provided as part of clinical care that meet at least two-thirds of an average individual's daily nutrient and energy needs and are provided in specified quantities to constitute the majority of the member's diet during the intervention.

Integration with careMTM must be integrated into clinical care and designed/overseen by an RDN or appropriate clinician as part of the member's treatment plan.

Quantity requirementMust be provided in specified quantities to constitute the majority of the member's diet over the course of the intervention to have intended health impact.

Step-down relationshipMTM may transition to medically supportive foods (MSF) as a step-down when clinically appropriate.

inv-12: Medically supportive food (MSF) — supplemental grocery packages adhering to guidelines to prevent/manage/reverse nutrition-sensitive conditions

DefinitionSupplemental grocery packages that adhere to national nutrition guidelines to prevent, manage, or reverse nutrition-sensitive conditions and are intended as a step-down from medically tailored meals where appropriate.

OversightMSF services must be overseen and signed off by a registered dietitian nutritionist (RDN) or another appropriate clinician.

PurposeIntended to be supplemental to a member's diet rather than to constitute the majority of intake; offered as a step-down intervention from MTM when clinically indicated.

Nutrient expectationsMSF packages adhere to national nutrition guidelines; MTM/MTG assistance still must meet at least two-thirds daily nutrient/energy needs when MTG are used to constitute major portion of diet.