Zaya Payers Coverage/Coding Guidelines

This document is an overview of the Nutritional Counseling coverage criteria that Zaya payers make available to providers on their sites.  This overview includes coverage considerations for Aetna, Anthem BCBS, Cigna, Oscar, and UHC.  Understanding this criteria will help you submit more accurate and complete claims and increase the likelihood of coverage.A key takeaway from many of the policies below is that most payers require providers to include the diagnosis codes for the condition leading to nutritional counseling on each claim that is submitted.

Aetna

Aetna has a policy specifically for Nutritional Counseling. While they accept ICD-10 Code Z71.3 (dietary counseling and surveillance), providers must also submit the relevant medical and/or BMI ICD-10 codes associated with the patient’s nutritional services. These will be reviewed against Aetna's coverage policy.

Payer Considered Indications:

• Adult Obesity

• Pediatric Obesity (aged 19 or under)

• Overweight adults with cardiovascular risk (hypertension, dyslipidemia, metabolic diseases, cardiovascular and coronary artery diseases)

• Eating Disorders

• Hypertension

• Kidney Disease

• COPD

• Patients with seizure disorders on a ketogenic diet

• Digestive System Disorders

Exclusions:

• ADHD

• Asthma

• Chronic Fatigue Syndrome

Anthem BCBS

Nutritional counseling criteria are part of Anthem’s preventive care programs. Anthem requires providers to submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Coverage Details:

• Limited to 12 units per calendar/plan year (combined total for 97802 and 97803)

• Coverage can vary by plan

Payer Considered Indications:

• Cardiovascular Risk Prevention (including cardiovascular disease, diabetes, pregnancy-related cardiac concerns, hyperlipidemia, hypertension, and kidney disease)

• Obesity in adults

• Overweight adults

• Pediatric Obesity (under age 18)

• Pre-Diabetes Prevention

• Healthy Weight in Pregnancy

• Type 2 Diabetes Prevention

Cigna

Cigna outlines criteria for Nutritional Counseling in their Preventive Care Policy. For preventive care, Cigna requires providers to define the type of visit being performed, ICD-10 Codes, like Z71.3 (dietary counseling and surveillance), define the type of visit that is taking place.Be sure to use the correct code to define the type of visit being performed, and remember, it is important to also submit the medical and/or BMI ICD-10 codes associated with the patient’s nutritional services.

Coverage Details:

Cigna has a strict limit of 3 visits per year for all indications, combined for visits billed under 97802 and 97803.

Payer Considered Indications:

• Cardiovascular Risk Prevention (including cardiovascular disease, diabetes, pregnancy-related cardiac concerns, hyperlipidemia, hypertension, and kidney disease)

• Obesity in adults

• Pediatric Obesity

• Pregnancy-Related Concerns

Oscar

Oscar has a policy for Medical Nutritional Therapy. Providers must submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Payer Considered Indications:

• Endocrine and Metabolic Disorders

• Eating Disorders

• Patients with seizure disorders on a ketogenic diet

• Hypertension

• Cardiovascular and coronary artery disease

• COPD

• Diseases of the stomach and esophagus

• Gastrointestinal disorders

• Endocrine Organ Disease

• Intestinal Malabsorption

• Pregnancy Concerns

• Overweight Adults

• Adult Obesity

• Pediatric Obesity

• Underweight Pediatric Patients

Exclusions:

• ADHD

• Asthma

• Chronic Fatigue Syndrome

• Depression

• Anxiety Disorders

• Autism Spectrum Disorder

• Non-Celiac Gluten Sensitivity

UHC

UHC provides criteria for Nutritional Counseling in their Preventive Care Policy. Providers must submit both the medical and/or BMI ICD-10 codes along with ICD-10 Code Z71.3 (dietary counseling and surveillance).

Payer Considered Indications:

• Cardiovascular Risk Prevention (including cardiovascular disease, diabetes, pregnancy-related cardiac concerns, hyperlipidemia, hypertension, and kidney disease)

• Weight loss for overweight and obese adults

• Obesity in Children and Adolescents

• Healthy Weight in Pregnancy

• Type 2 Diabetes Prevention