Oscar Medical Nutrition Therapy (CG010) Form

Medical Nutrition Therapy includes dietary evaluation and counseling from a licensed healthcare professional for optimal management of a disease process, illness, or medical condition.

The Plan considers Medical Nutrition Therapy medically necessary for acute and chronic diseases and medical conditions where scientific evidence has demonstrated that dietary intake is or can be a critical component of the treatment plan. The Plan's expectation is that licensed dietary specialists will provide care as part of a coordinated, multidisciplinary team effort that includes the primary care physician, and that considers all aspects of the member’s health including all relevant medical conditions, medications, other treatments, social and cultural factors and personal dietary preferences.

The role of Medical Nutrition Therapy is to reduce the risk of developing complications from newly diagnosed conditions, as well as to reduce the effects of chronic medical conditions on end-organ function and on the general physical health and welfare of members. The Plan does not consider Medical Nutrition Therapy for conditions in which it has not been scientifically proven to be clinically effective or in which the efficacy is not clearly established in the medical literature by high-quality, peer-reviewed evidence.

Definitions

"Medical Nutrition Therapy" is a therapeutic approach to treating medical conditions via the use of specific diets devised and monitored by qualified licensed health professionals with expertise in nutrition and dietary therapy. Comprehensive evaluation for medical nutrition therapy includes medical history, physical examination, anthropometric measurements, and laboratory values, and, when medically indicated, ongoing reassessment. Nutrition therapy includes dietary evaluation and modification, training for self management or specialized therapies, counseling and education.

"Initial Assessment and Intervention" is the comprehensive evaluation with a licensed health professional qualified to evaluate the dietary components of one or more medical conditions in order to establish a therapeutic dietary program.

"Reassessment and Intervention" is the provision of ongoing medical nutrition therapy and support for members with an established therapeutic dietary program and who have been determined to require ongoing monitoring to assess for metabolic efficacy, weight loss or gain, or other clinical benefit. Reassessment and intervention are subject to review for medical necessity.

"Licensed Healthcare Professional" is a professional licensed in an appropriate field who is qualified to provide Medical Nutrition Therapy. Examples include, but are not limited to, Registered Dietitians (RD), Registered Dietitian Nutritionists (RDN), Certified Nutritionists (CNS or CCN), Licensed Dietitian-Nutritionists (LDN), and certain physicians specializing in nutritional medicine or with expertise in the study of food and nutrition science.

Clinical Indications

General Criteria

A comprehensive dietary consultation should establish therapeutic goals to include all of the member’s comorbid conditions. Initiation of medical nutrition therapy must contain the following elements:

1. Documentation that nutrition therapy has a therapeutic role in the member’s treatment; and
2. Documentation of measurable goals as submitted from a licensed medical professional and/or licensed nutritionist, registered dietician; and
3. Dietary plan/recommendations as submitted from a licensed medical professional and/or licensed nutritionist, or registered dietician.

Clinical Indications

1. Newly Diagnosed or Chronic Health Conditions: The Plan considers dietary evaluation and counseling medically necessary to evaluate, establish and reassess a dietary program for members of any age when ALL of the following are present:
   • a. The therapy was prescribed by a licensed healthcare provider; and
   • b. The therapy is for a new or existing condition diagnosed by a licensed healthcare provider that presents a threat to the member’s general health; and

Dietary adjustment has an established therapeutic role in modifying and/or controlling the condition, with such conditions being included on the list below:

Neurological Conditions

• Epilepsy and intractable seizure disorders that would benefit from specific dietary restrictions or interventions (e.g., requiring ketogenic diet)

Systemic and Cardiovascular Conditions

• Cardiomyopathy (e.g., requiring limited fluid intake)
• Cardiovascular disease (e.g., requiring weight loss or decreased fat intake diet)
• Chronic obstructive pulmonary disease (COPD) (e.g., requiring limited fluid intake)
• End stage renal disease (e.g., diets with strict electrolyte limitations)
• Heart failure (e.g., requiring weight loss, limited fluid intake, or other dietary measures)
• Hypertension (e.g., requiring lowered-sodium diet)
• Diagnosed with a severe food allergy (e.g., requiring strict dietary control and avoidance of specific substances) such as gluten-intolerance or lactose-intolerance

Disorders of the Intestinal Tract

• Any condition requiring Nasogastric tube feeding, PEG feeding, intravenous infusion or parenteral nutrition, or any medical conditions preventing the consumption of food via the mouth
• Diagnosed Celiac disease (e.g., requiring a Gluten-free diet)
• Inflammatory bowel disease (e.g., requiring specific diet)
• Intestinal obstruction (e.g., requiring specific dietary interventions)
• Noninfectious gastroenteritis and colitis (e.g., requiring specific diet)
• Regional enteritis (e.g., requiring specific diet)
• Vascular insufficiency of intestines (e.g., requiring specific diet)

Metabolic and Nutritional Disorders

• Diabetes (e.g., ADA diet, requiring controlled carbohydrate counting), Prediabetes (e.g., requiring controlled carbohydrate diet), or diabetic ketoacidosis
• Eating disorders including Anorexia Nervosa and Bulimia (requiring strict dietary control and close reassessment)
• Failure to Thrive (e.g., requiring strict dietary control and close reassessment)
• Hyperlipidemia / Hypercholesterolemia (e.g., requiring diets low in saturated fat)
• Inborn errors of metabolism, genetic disorders (e.g., requiring low-protein or specialized diets or formulas)
• Malnutrition (e.g., requiring strict dietary control and close reassessment)
• Nutritional marasmus (e.g., requiring strict dietary control and close reassessment)
• Obstructive sleep apnea (e.g., requiring weight loss)
• Rickets (Vitamin D deficiency) (e.g., requiring Vitamin D and Calcium controlled diet)

Pregnancy

1. The Plan considers dietary evaluation and counseling medically necessary in pregnancy if requested to assist a pregnant member with appropriate dietary choices in certain clinical conditions. These conditions include, but are not limited to:
   • a. Pre-eclampsia or eclampsia (high blood pressure of pregnancy)
   • b. Hyperemesis Gravidarum
   • c. Multiple gestation pregnancy
   • d. Gestational Diabetes

Weight Management

The Plan considers dietary evaluation and counseling medically necessary for members with over or underweight conditions as diagnosed by a licensed provider. The Plan follows guidelines established by the United States Centers for Disease Control and Prevention (CDC) in using Body Mass Index, or BMI, to classify members as underweight, overweight or obese:

• Underweight: BMI less than 18.5
• Overweight: BMI 25 to 29.9
• Class 1 Obesity: BMI 30 to 34.9
• Class 2 Obesity: BMI 35 to 39.9
• Class 3 Obesity (also known as “extreme,” “severe,” or “Morbid” Obesity): BMI 40 or higher

Weight Loss Surgery (Bariatric) Patients

The Plan considers dietary evaluation and counseling medically necessary for members who are being evaluated for and/or approved for bariatric (weight loss) surgery, both pre and post operatively. Specific requirements for bariatric surgery can be found in G008: Bariatric Surgery (Adults) and CG009: Bariatric Surgery (Adolescents).

Continued Care

Criteria for Continuing Treatment After Initial Trial

Continued dietary evaluation and counseling are subject to review for medical necessity and must contain the following elements:

1. Documentation that nutrition therapy has a therapeutic role (chronic); and
2. Documentation of changes in medical condition, diagnosis, or treatment regimen that requires further intervention; and
3. Evidence of member adherence to diet prescribed; and
4. Evidence that additional counseling would be helpful or beneficial to member’s health; and
5. Documentation of measurable goals as submitted by a licensed medical professional and/or licensed nutritionist, registered dietician.

Home Care - Nutritional Therapy

The Plan considers dietary evaluation and counseling medically necessary when received in the home from a participating home care agency if ALL of the following are met:

Member meets one of the above criteria for Medical Nutrition Therapy.

Experimental or Investigational / Not Medically Necessary

The Plan does not consider dietary evaluation and counseling medically necessary for medical conditions that have not been demonstrated to be nutritionally related by evidence-based studies available in the medical literature. These medical conditions include, but are not limited to:

• Anxiety or other mood disorders
• Asthma
• Autism spectrum disorder
• Attention-deficit hyperactivity disorder (ADHD)
• Chronic fatigue syndrome
• Gluten-sensitivity disorder
• Major depressive disorder

A family history of a condition alone is not sufficient for medical necessity of Medical Nutrition Therapy. A qualifying condition must be diagnosed in the member or in the member’s unborn fetus.

The Plan does not consider Medical Nutrition Therapy for members seeking counseling for dietary regimens that are considered to personal preference medically necessary including, but not limited to, vegetarian, vegan, pescatarian, low-gluten, or other specialty diets.

Medical Nutrition Therapy is not considered medically necessary when it is provided in an emergency room or urgent care setting.