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Tufts Health Plan 60-Day Notification

Effective January 1, 2009 - Coverage Updates for Commercial Products
Tufts Health Plan implements changes to its coverage for commercial products throughout the year. The following changes are effective as of January 1, 2009:

Continuous Glucose Monitoring Systems
The following codes will be added to the new Medical Necessity Guidelines for Continuous Glucose Monitoring Systems:

  • A9276: Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, 1 unit = 1 day supply
  • A9277: Transmitter; external, for use with interstitial continuous glucose monitoring system
  • A9278: Receiver (monitor); external, for use with interstitial continuous glucose monitoring system
  • S1030: Continuous noninvasive glucose monitoring device, purchase; and S1031: rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)

Cochlear Implants
The following codes will be added to the Medical Necessity Guidelines for Cochlear Implants:
  • L8615: Headset/headpiece for use with cochlear implant device, replacement
  • L8616: Microphone for use with cochlear implant device, replacement
  • L8617: Transmitting coil for use with cochlear implant device, replacement
  • L8618: Transmitter cable for use with cochlear implant device, replacement
  • L8619: Cochlear implant external speech processor, replacement
  • L8621: Zinc air battery for use with cochlear implant device, replacement, each
  • L8622: Alkaline battery for use with cochlear implant device, any size, replacement, each
  • L8623: Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each
  • L8624: Lithium ion battery for use with cochlear implant device speech processor, ear level, replacement, each

Intrathecal Pump for the Infusion of Baclofen
The following codes will be added to the Medical Necessity Guidelines for Intrathecal Pump for the Infusion of Baclofen:
  • 62350: Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump, without laminectomy; and 62351: with laminectomy
  • 62360: Implantation or replacement of device for intrathecal or epidural drug infusion, subcutaneous reservoir; 62361: Non-programmable pump; and 62362: programmable pump, including preparation of pump, with or without programming
  • E0785: Implantable intraspinal (epidural/intrathecal) catheter used with implantable infusion pump, replacement
  • 62367: Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming; and 62368: with reprogramming

Statements of Non-Coverage
The following procedures will not be covered and will be added to the Statements of Non-Coverage Medical Necessity Guidelines:
  • Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence (No CPT code available)
  • Home Uterine Activity Monitoring (S9208, S9209)
  • Genetic Testing for Narcolepsy (no CPT or HCPCS code available)



November 1, 2008