Provider : Ccgs

 

The Clinical Coverage Guidelines (CCG) are evidence-based documents detailing the medical necessity of given procedures or technologies. The guidelines set consistent criteria for the coverage of a procedure or technology, leading to greater consistency and efficiency in clinical decision making. This consistency and efficiency results in better provider-company interactions and increases the quality of our members' health.

 

Click on the desired link below to open or download a copy of WellCare’s CCGs, which are sorted alphabetically. Guidelines listed as IN REVIEW are currently in the approval process; the date listed is the most current copy of the guideline.  Guidelines listed as REVISED have been reviewed and are current as of the date listed.

 

Note: A new template was approved for use by the Medical Policy Committee on 12/1/2011. Guidelines are in the process of being updated to reflect the change. 

 

If you wish to search by keyword or acronym to find a particular CCG, please type CTRL-F and in the “Find and Replace” dialog box, type the keyword or acronym you wish to search by.

 

A

• Ablation System for Atrial Fibrillation Cardioblate®  REVISED August 2011
• Absorbent Products Hawaii REVISED May 2011
• Acupuncture REVISED August 2011
• AcuTect Scintigraphic Imaging for Deep Vein Thrombosis REVISED September 2011
• Adenosine Stress Test December 2010
• Air Fluidized Beds REVISED August 2011
• Altered Auditory Feedback Devices SpeechEasy for the Treatment of Stuttering REVISED March 2011
• Ambulatory and Video Electroencephalography EEG for Epilepsy REVISED July 2011
• Ambulatory Blood Pressure Monitoring REVISED August 2011
• Antepartum Fetal Surveillance REVISED August 2011
• Anterior Cingulotomy for Treatment of Obsessive Compulsive Disorder REVISED March 2011
• Antineoplaston Therapy REVISED August 2011
• Aquatic Therapy REVISED September 2011
• Artificial Disc Replacement REVISED September 2011
• Artificial Heart Devices IN REVIEW September 2010
• Autologous Blood Derived Growth Factors Platelet Rich Plasma REVISED August 2011

 

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B

• Bariatric Surgery REVISED July 2011
• Biofeedback to Lower Blood Pressure Using the RESPeRATE Device REVISED July 2011
• Blepharoplasty REVISED September 2011
• Bone Anchored Hearing Aid BAHA REVISED September 2011
• Bone Mass Measurement REVISED August 2011
• Breast Pumps REVISED August 2011
• Breast Specific Gamma Imaging REVISED September 2011
• Bronchial Thermoplasty REVISED June 2011

 

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C

• Cardiac Computed Tomography CT Angiography REVISED February 2011
• Cardiac Rehabilitation REVISED March 2011
• Celiac Disease DNA Testing REVISED July 2011
• Chelation Therapy REVISED March 2011
• Chronic Intermittent Intravenous Insulin Therapy CIIIT REVISED February 2011
• Chronic Vertigo Treatments REVISED July 2011
• Circumcision FL Medicaid Only REVISED February 2011
• Clinical Trials Coverage of Investigational Devices IN REVIEW November 2010
• Clinical Trials Coverage of Routine Patient Care Costs REVISED March 2011
• Cochlear Implant REVISED September 2011
• Cognitive Rehabilitation REVISED April 2011
• Collagen Meniscus Implant Medicare REVISED August 2011
• Computed Tomography Colonography Virtual Colonoscopy REVISED January 2011
• Computed Tomography CT Perfusion Imaging REVISED March 2011
• Continuous Glucose Monitoring IN REVIEW October 2010
• Continuous Positive Airway Pressure CPAP for Treatment of Obstructive Sleep Apnea in Adults IN REVIEW April 2010
• Cranial Electrotherapy Stimulation REVISED August 2011
• Cranial Remodeling with Orthotic Devices REVISED August 2011
• Craniosacral Therapy REVISED September 2011

 

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D

• deCODE Prostate Cancer Test IN REVIEW December 2010
• Deep Brain Stimulation for Essential Tremor and Parkinson's Disease IN REVIEW January 2011
• Dermal Injections for Facial Lipodystrophy Syndrome FLS IN REVIEW October 2010
• Diagnostic and Predictive Genetic Testing REVISED August 2011
• Diaphragmatic Phrenic Nerve Stimulation REVISED August 2011
• Dynamic Stretching Devices REVISED July 2011

 

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E

• Electrical Impedance Scanning for Breast Cancer IN REVIEW October 2010
• Electrical Stimulation for Constipation E/I REVISED August 2011
• Electrical Stimulation for Wound Healing REVISED August 2011
• Electro Acuscope Myopulse Therapy System IN REVIEW March 2011 EI
• Electroconvulsive Therapy IN REVIEW December 2010
• Epidural Adhesiolysis IN REVIEW October 2010
• Erythropoiesis Stimulating Agents for Cancer and Other Related Neoplastic Conditions RETIRED January 2012
• Excimer Laser Therapy for Skin Conditions REVISED August 2011
• Exhaled Nitric Oxide Measurement for Respiratory Disorders REVISED August 2011
• Experimental and Investigational Procedures and Devices IN REVIEW October 2010
• External Counterpulsation REVISED August 2011
• Extracorporeal Shock Wave Therapy REVISED August 2011
• Eye Movement Desensitization Therapy IN REVIEW December 2010

 

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F

• Fecal DNA Test for Colorectal Cancer REVISED September 2011
• Fetal Echocardiography Including Doppler Pulsed Wave and Color Flow Mapping REVISED August 2011
• Fetal Ultrasound Assessment of Nuchal Translucency REVISED August 2011

 

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G

• Gait Analysis IN REVIEW April 2010
• Gastric Electrical Stimulation Gastric Pacing for Gastroparesis REVISED March 2011
• Genetic Assay for Breast Cancer Oncotype Dx REVISED February 2011
• Genetic Testing for Alzheimer's Disease IN REVIEW November 2010
• Genetic Testing for Breast and Ovarian Cancer BRCA REVISED August 2011
• Genetic Testing for Cystic Fibrosis REVISED August 2011
• Genetic Testing for Factor V Leiden IN REVIEW November 2010
• Genetic Testing for Familial Adenomatous Polyposis REVISED March 2011
• Genetic Testing for Fragile X Syndrome REVISED August 2011
• Genetic Testing for Hereditary Non-Polyposis Colorectal Cancer HNPCC REVISED February 2011
• Genetic Testing for Long QT Syndrome REVISED January 2011
• Genetic Testing for Neurofibromatosis NF1 IN REVIEW October 2010
• Genetic Testing for Tuberous Sclerosis Complex IN REVIEW November 2010
• Genotypic and Phenotypic Assays for HIV Drug Resistance REVISED July 2011
• Gestational Diabetes Education Program REVISED July 2011

 

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H

• Hearing Aids Adult REVISED March 2011
• Heart Transplant Rejection Tests Heartsbreath and Allomap IN REVIEW November 2010
• Heating Pad Systems IN REVIEW October 2010
• Helicobacter Pylori Breath Testing REVISED September 2011
• HER2 Neu Testing for Breast Cancer REVISED August 2011
• Hippotherapy REVISED July 2011
• High Frequency Chest Wall Oscillation Devices REVISED August 2011
• Histamine Desensitization Therapy IN REVIEW December 2010
• Home Cholesterol Monitors REVISED August 2011
• Home Phototherapy for Hyperbilirubinemia REVISED September 2011
• Home Prothrombin Time Monitoring REVISED January 2011
• Home Uterine Activity Monitoring HUAM IN REVIEW June 2010
• Hyperbaric Oxygen Therapy REVISED August 2011

 

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I

• Implantable Wireless Abdominal Aortic Aneurysm Pressure Management System EndoSure® REVISED August 2011
• In Vitro Chemoresistance and Chemosensitivity Assays IN REVIEW November 2010
• In Vitro IgE Antibody Allergy Testing REVISED September 2011
• Inhaled Nitric Oxide iNO Therapy in Infants REVISED July 2011
• Insulin Potentiation Therapy REVISED July 2011
• Insulin Pump External and Subcutaneous Insulin Delivery REVISED August 2011
• Intensity Modulated Radiation Therapy IMRT REVISED April 2011
• Interferential Therapy REVISED August 2011
• Interstitial Laser Therapy for Breast Tumors IN REVIEW November 2010
• Intracranial Stenting and Angioplasty REVISED July 2011
• Intradiscal Electrothermal Therapy IDET REVISED September 2011

 

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K

• KRAS Sequence Variant Analysis for Metastatic Colorectal Cancer IN REVIEW October 2010

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L

• Long Term Acute Care Hospital Admission Criteria REVISED July 2011
• Low-Level Light Therapy IN REVIEW December 2010

 

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M

• Mastectomy for Gynecomastia IN REVIEW November 2010
• Microvolt T Wave Alternans REVISED February 2011

 

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N

• Negative Pressure Wound Therapy REVISED January 2011
• Neuromuscular Electrical Stimulation NMES REVISED September 2011
• Noncontact Normothermic Wound Therapy IN REVIEW October 2010

 

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O

• OB Ultrasound Including Standard Limited Comprehensive Targeted and Follow Up REVISED August 2011
• OB Ultrasound 3D and 4D Imaging REVISED August 2011
• Ocular Photodynamic Therapy with Visudyne REVISED August 2011
• Oral Appliances for Obstructive Sleep Apnea IN REVIEW November 2010
• Oral Function Therapy for Pediatric Feeding Disorders REVISED September 2011
• Orthognathic Surgery REVISED March 2011
• Osteogenic Stimulation REVISED August 2011
• Outpatient Management of Preeclampsia REVISED July 2011
• Outpatient Pulmonary Rehabilitation IN REVIEW January 2010
• Outpatient Rehabilitation Services REVISED September 2011
• Oxygen Use REVISED March 2011

 

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P

• Palatal Impant System Pillar® for Obstructive Sleep Apnea NEW March 2011
• Panniculectomy and Abdominoplasty REVISED August 2011
• PathFinderTG® Molecular Testing Topographic Genotyping REVISED February 2011
• Pathwork® Tissue of Origin Test REVISED August 2011
• Pediatric Continuous Positive Airway Pressure CPAP for the Treatment of Obstructive Sleep Apnea IN REVIEW April 2010
• Pediatric Hearing Amplification REVISED September 2011
• Percutaneous Transluminal Angioplasty IN REVIEW October 2010
• PET Scan for Cardiac Applications REVISED August 2011
• PET Scan for Dementia and Neurodegenerative Disease REVISED February 2011
• PET Scan for Solid Tumors REVISED August 2011
• Pharmacogenomic Testing for Warfarin Response REVISED September 2011
• Phonophoresis REVISED March 2011
• PLAC Test for Prediction of Coronary Heart Disease and Ischemic Stroke REVISED February 2011
• Plantar Fasciitis Treatments REVISED August 2011
• Plasmin Assisted Vitrectomy REVISED August 2011
• Postoperative Disposable Ambulatory Regional Anesthesia PDARA REVISED July 2011
• Progesterone for the Prevention of Preterm Birth in High Risk Women RETIRED January 2012
• Prolotherapy for Treatment of Joint and Ligamentous Conditions IN REVIEW December 2010
• Prostate Px® Test for the Prediction of Recurrence of Prostate Cancer REVISED February 2011
• Proteomic Based Testing for Ovarian Cancer OvaCheck REVISED September 2011
• Proton Beam Therapy REVISED August 2011
• Pulse Oximetry for Home Use REVISED July 2011

 

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R

• Reduction Mammoplasty IN REVIEW October 2010

 

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S

• Seat Lift Mechanisms REVISED July 2011
• Sensory and Auditory Integration Therapy, Facilitated Communications REVISED March 2011
• Serological Testing for Inflammatory Bowel Disease NEW October 2010
• Skilled Therapy Services for Children with Developmental Delay Florida IN REVIEW October 2010
• Skilled Therapy Services for Children with Developmental Delay Missouri IN REVIEW November 2010
• Skilled Therapy Services Ohio REVISED September 2011
• Speech Generating Devices REVISED August 2011
• Spinal Cord Stimulation Implant REVISED August 2011
• Spinal Ultrasound REVISED August 2011
• Spinal Unloading Devices IN REVIEW November 2010
• Stem Cell Transplantation REVISED August 2011
• Subtalar Implant REVISED August 2011
• Supprelin LA Subcutaneous Implant for the Tx of Central Precocious Puberty CPP RETIRED January 2012
• Surgical Correction of Chest Wall Deformities Pectus Excavatum and Pectus Carinatum REVISED August 2011

 

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T

• Telehealth Home Care Services New York Medicaid REVISED January 2011
• Terbutaline Pump for Preterm Labor REVISED August 2011
• Testosterone Pellets Implantable Testopel NEW March 2011
• Therapeutic Cooling Devices IN REVIEW October 2010
• Therapy Services for Children with Chronic Conditions Georgia IN REVIEW September 2010
• Thoracic Electrical Bioimpedance for Cardiac Output Monitoring REVISED July 2011
• Tilt Table Testing REVISED August 2011
• Tobacco Cessation Counseling Medicare REVISED September 2011
• Topical Oxygen Wound Therapy IN REVIEW December 2010
• Total Hip Resurfacing REVISED February 2011
• Transcranial Magnetic Stimulation IN REVIEW December 2010
• Transcutaneous Electrical Joint Stimulation for the Treatment of Arthritis REVISED July 2011
• Transurethral Microwave Thermotherapy TUMT REVISED September 2011
• Transvaginal Ultrasound REVISED August 2011
• Treatment for Peripheral Lymphedema including Pneumatic Compression Devices REVISED February 2011
• Treatment of Nausea and Vomiting in Pregnancy with Subcutaneous Pump REVISED August 2011
• Trigger Point Injections REVISED August 2011

 

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U

• Ultrasound Therapy for Wound Healing Mist Therapy REVISED February 2011
• Ultraviolet Light Therapy for Skin Conditions REVISED August 2011
• Urinary Incontinence Treatments REVISED February 2011

 

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V

• Vacuum Assisted Socket System VASS REVISED March 2011
• Vagus Nerve Stimulation for Epilepsy IN REVIEW December 2010
• Vagus Nerve Stimulation for Treatment Resistant Depression REVISED August 2011
• Vantas Implant for the Treatment of Advanced Prostate Cancer REVISED July 2011
• Vertebral Axial Decompression Therapy VAX D REVISED September 2011
• Viscocanalostomy and Canaloplasty REVISED August 2011
• Visual Evoked Potential Studies REVISED August 2011
• Voice Prosthesis for Voice Rehab Following Total Laryngectomy REVISED February 2011

 

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W

• Wearable and Automatic External Defibrillators for the Prevention of Sudden Cardiac Death REVISED August 2011
• Whole Body CT Screening REVISED July 2011
• Wireless Capsule Endoscopy REVISED July 2011

 

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X

• X Stop Interspinous Process Decompression Device REVISED August 2011

 

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The Clinical Coverage Guideline is intended to supplement certain standard WellCare benefit plans. The terms of a member’s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member’s benefit plan may contain specific exclusions related to the topic addressed in this Clinical Coverage Guideline. When a conflict exists between the two documents, the Member’s Benefit Plan always supersedes the information contained in the Clinical Coverage Guideline. Additionally, Clinical Coverage Guidelines relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any.