providers

Tufts Health Plan 60-Day Notification
Effective January 1, 2010
Coverage Updates for Commercial Products

2009 InterQual® Criteria
Effective December 14, 2009, Tufts Health Plan will adopt 2009 InterQual® criteria in making clinical coverage determinations.

Tufts Health Plan requires submission of an InterQual® SmartSheet™ for prior authorization of some procedures, services and items. For dates of service on or after December 14, 2009, providers should submit the 2009 version when requesting prior authorization for any procedure for which an InterQual® SmartSheet™ is required. Submitting the previous version will delay processing of the authorization request.

Refer to the InterQual® SmartSheet™ Required Procedures List for a list of services that require an InterQual® SmartSheet™. The InterQual® SmartSheets™ for those procedures can be found on the secure Provider Web site or by calling Provider Services.

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

Prior Authorization
Effective for dates of service on or after January 1, 2010, the following procedures and services will require prior authorization for members 18 years of age and older: :


The following codes will be added to existing prior authorization programs:
Non-Covered Services
Effective for dates of service on or after January 1, 2010, the following procedures 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:
  • Cranialsacral Therapy
  • Endoscopic Laser-Assisted Discectomy for Cervical Disc Herniation
  • Intravascular Ultrasound (IVUS) for Assessment of Peripheral Artery Disease (PAD) of the Lower Extremities (37250, 37251 with a diagnosis of 440.20 – 440.29, 443.9)
  • Laparoscopic Sleeve Gastrectomy for Super Obesity
  • Laparoscopic Ileal Interposition and Sleeve Gastrectomy for Treatment of Type 2 Diabetes
  • Multichannel Intraluminal Impedance Testing for GERD (91037, 91038)
  • Percutaneous Mechanical Thrombectomy for Acute Limb Ischemia with the AngioJet® Rheolytic Thrombectomy System (Possis Medical, Inc.)
  • Platelet-Rich Plasma (PRP) for Bone Healing and Fusion
  • Pathwork® Tissue of Origin Test Gene Expression-Based Test
  • Urinary Microsatellite Analysis
  • Wireless Capsule for Measuring Gastric Emptying (SmartPill GI Monitoring System®) (91299)

Other Coverage Updates
  • Hysterectomy:  Effective January 1, 2010, the Medical Necessity Guidelines for Elective Hysterectomy have been updated regarding dysfunctional uterine bleeding. An Organizational Policy Note (OPN) has been added requiring endometrial ablation.
  • Upper GI Endoscopy: Celiac Sprue Diagnosis: Effective January 1, 2010, Celiac Sprue Diagnosis has been added to the current Upper GI Endoscopy prior authorization program. Beginning January 1, 2010, providers should submit a letter of medical necessity instead of an InterQual® SmartSheet™ to request prior authorization for upper GI endoscopy for that diagnosis. Coverage criteria for those procedures are in the Medical Necessity Guidelines for Upper GI Endoscopy: Celiac Sprue Diagnosis.  
  • Spinal Procedures: Effective January 1, 2010, the following diagnoses and procedures have been added to the current prior authorization program for Spinal Procedures, Certain Elective:
    • Lumbar Fusion for the following diagnoses:
      • Isthmic Spondylolisthesis (any grade)
      • Degenerative Spondylolisthesis with or without Spinal Stenosis
      • Internal Lumbar Disc Disruption including Anterior Lumbar Interbody Fusion (ALIF)
      • Re-do Lumbar Fusion
    • Posterior Lumbar Decompression with Lumbar Spinal Fusion for Lumbar Spinal Stenosis
    • Posterior Decompression without Spinal Fusion for Spinal Stenosis
    • Hemilaminectomy, lumbar with or without discectomy/foraminotomy

November 1, 2009