Effective July 1, 2010
Coverage Updates for Commercial Products

Tufts Health Plan implements changes to its commercial coverage status throughout the year. The following changes are effective for dates of service on or after July 1, 2010.

Changes to Existing Prior Authorization Programs

• Upper GI Endoscopy: Effective July 1, 2010, Tufts Health Plan will institute new Medical Necessity Guidelines for coverage of upper GI endoscopy and will no longer utilize InterQual® criteria for these procedures. The Upper GI Endoscopy Prior Authorization Form, available in the Forms section of the Provider Web site, should be used to submit coverage requests for dates of service on or after July 1, 2010. The InterQual® SmartSheet™ for Upper GI Endoscopy will be of no further use after that date.
• Redundant Skin: Surgical Removal: The Medical Necessity Guidelines for surgical removal of redundant skin will be revised to clarify coverage considerations regarding non-medical and bariatric surgery weight loss.

Other Coverage Updates

• Epidural Injections: Coverage for epidural injections (62311, 64483, 64484) will be limited to a total of four dates of service per year and covered only when billed with the following ICD-9 diagnoses: 722.10, 724.02, 724.3, 724.4. These epidural injection codes will not be covered when billed with any other diagnosis code. Refer to the Anesthesia Payment Policy for details.
• High Dose Rate (HDR) Brachytherapy: HDR brachytherapy (0182T) will be covered only when billed with the following ICD-9 diagnoses: 174.0–174.9, 179.0, 180.0, 180.1, 180.8, 180.9 or 182.0. HDR brachytherapy will not be covered when billed with any other diagnosis code. For details, see the Statements of Non-Coverage Medical Necessity Guidelines.
• Microprocessor Controlled Prosthetic Knee (L5856, L5857, L5858) will be covered when criteria in the Medical Necessity Guidelines for Lower Limb Prostheses with Micro-Knee are met.
• Infertility Services: The requirement of 1–2 cycles of IUI will be removed for women ages 40–42. This change applies to infertility services covered by Tufts Health Plan policies issued under both Massachusetts and Rhode Island licenses.
• Speech Therapy: The Medical Necessity Guidelines for Speech Therapy will be revised to include coverage for the following ICD-9 diagnoses: 387.0–387.9, 388.10- 388.12, 389.10–389.18, 389.20–389.22, 744.00–744.09, 756.51, and 951.5.

Non-Covered Services
Effective for dates of service on or after July 1, 2010, the following procedure(s) will not be covered by Tufts Health Plan, as they are considered experimental/investigational, and will be added to the Statements of Non-Coverage Medical Necessity Guidelines:

• Platelet-Rich Plasma Infusion for all indications
• Oncotype Dx® for Colon Cancer Assay
• MitoMetSM (Mitochondrial/Metabolic Oligonucleotide Array CGH Analysis)
• Arrhythmogenic Right Ventricular Dysplasia/ Cardiomyopathy Testing
• CDKN2A Mutations Testing for Melanoma
• All Genetic Testing for Alzheimer’s
• Pharmacogenomic Testing for Warfarin Responsiveness

May 1, 2010
Updated: June 23, 2010
Note: The information in this article was correct as of the date of posting and may not reflect subsequent policy changes.