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Clinical Coverage Guidelines
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.
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 - B - C - D - E - F - G - H - I - J - K - L - M - N - O - P - Q - R - S - T - U - V - W - X - Y - Z
- Absorbent Products (Hawaii) HS-169
- Acupuncture HS-107
- AcuTect Scintigraphic Imaging for Deep Vein Thrombosis HS-132
- Adenosine Stress Test HS-146
- Air Fluidized Beds HS-117
- Ambulatory Blood Pressure Monitoring HS-041
- Antepartum Fetal Surveillance HS-111
- Anterior Cingulotomy for Treatment of Obsessive-Compulsive Disorder HS-068
- Artificial Disc Replacement HS-046
- Artificial Heart Devices HS-074
- Bariatric Surgery HS-006
- Bariatric Surgery for Diabetes HS-100 RETIRED: NO LONGER IN USE
- Biofeedback to Lower Blood Pressure Using the RESPeRATE Device HS-103
- Blepharoplasty HS-038
- Bone Mass Measurement HS-042
- Bone-Anchored Hearing Aid (BAHA) HS-045
- Breast Pumps HS-027
- Breast-Specific Gamma Imaging HS-129
- Bronchial Thermoplasty HS-170
- Canalith Repositioning HS-176
- Canaloplasty HS-126
- Cardiac Computed Tomography (CT) Angiography HS-022
- Cardiac Output Monitoring Using Thoracic Electrical Bioimpedance HS-106
- Cardiac Rehabilitation HS-091
- Celiac Disease DNA Testing HS-163
- Chelation Therapy HS-092
- Chronic Intermittent Intravenous Insulin Therapy (CIIIT) HS-085
- Circumcision (FL Medicaid Only) HS-151
- Clinical Trials, Coverage of Routine Patient Care Costs HS-090
- Clinical Trials, Coverage of Investigational Devices HS-144
- Cochlear Implant HS-039
- Cognitive Rehabilitation HS-095
- Collagen Meniscus Implant HS-172
- Computed Tomography (CT) Perfusion Imaging HS-161
- Continuous Glucose Monitoring HS-138
- CPAP in Adults HS-008
- Cranial Electrotherapy Stimulation HS-178
- Cranial Remodeling with Orthotic Devices HS-009
- Craniosacral Therapy HS-128
- deCODE Prostate Cancer Test HS-147
- Deep Brain Stimulation for Essential Tremor and Parkinson's Disease HS-075
- Dermal Injections for Facial Lipodystrophy Syndrome (FLS) HS-134
- Dynamic Stretching Devices HS-164
- Electrical Impedance Scanning (for Breast Cancer) HS-054
- Electrical Stimulation for Constipation HS-150
- Electrical Stimulation for Wound Healing HS-125
- Electroconvulsive Therapy HS-070
- Epidural Adhesiolysis HS-053
- Erythropoiesis Stimulating Agents for Cancer and Other Related Neoplastic Conditions HS-059
- Excimer Laser Therapy for Skin Conditions HS-173
- Experimental and Investigational Procedures and Devices HS-136
- Extracorporeal Shock Wave Therapy HS-037
- External Counterpulsation HS-035
- Eye Movement Desensitization Therapy HS-071
- Gait Analysis HS-096
- Gastric Electrical Stimulation HS-086
- Genetic Assay for Breast Cancer (Oncotype Dx) HS-079
- Genetic Testing HS-021
- Genetic Testing for Alzheimer's Disease HS-055
- Genetic Testing for Breast and Ovarian Cancer (BRCA) HS-113
- Genetic Testing for Cystic Fibrosis HS-026
- Genetic Testing for Factor V Leiden HS-056
- Genetic Testing for Fragile X Syndrome HS-123
- Genetic Testing for Familial Adenomatous Polyposis HS-160
- Genetic Testing for Hereditary Non-Polyposis Colorectal Cancer (HNPCC) HS-154
- Genetic Testing for Long QT Syndrome HS-148
- Genetic Testing for Neurofibromatosis (NF1) HS-135
- Genetic Testing for Tuberous Sclerosis Complex HS-143
- Gestational Diabetes Education Program HS-167
- Hearing Aids-Adult HS-159
- Heart Transplant Rejection Tests (Heartsbreath and Allomap) HS-060
- Heating Pad Systems HS-133
- Helicobacter Pylori Breath Testing HS-131
- HER2-Neu Testing for Breast Cancer HS-121
- Hippotherapy HS-168
- High-Frequency Chest Wall Oscillation Devices HS-036
- Histamine Desensitization Therapy HS-066
- HIV Drug Resistance Assays HS-165
- Home Cholesterol Monitors HS-110
- Home Phototherapy for Hyperbilirubinemia HS-127
- Home Uterine Activity Monitoring HS-013
- Hyperbaric Oxygen Therapy HS-032
- Implantable Wireless Abdominal Aortic Aneurysm Pressure Management System (EndoSure®) HS-175
- In Vitro Chemoresistance and Chemosensitivity Assays HS-061
- Inhaled Nitric Oxide (iNO) Therapy in Infants HS-063
- Insulin Potentiation Therapy HS-105
- Insulin Pump HS-001
- Intensity-Modulated Radiation Therapy HS-094
- Interferential Therapy HS-118
- Interstitial Laser Therapy for Breast Tumors HS-142
- Intracranial Stenting and Angioplasty HS-017
- Intradiscal Electrothermal Therapy (IDET) HS-043
L
- Long-Term Acute Care Hospital Admission Criteria HS-162
- Low-Level Light Therapy HS-072
- Lymphedema Treatment HS-078
- Negative Pressure Wound Therapy HS-077
- Neuromuscular Electrical Stimulation (NMES) HS-048
- Noncontact Normothermic Wound Therapy HS-052
- Nuchal Translucency HS-108
- OB Ultrasound HS-002
- OB Ultrasound - 3D and 4D HS-109
- Ocular Photodynamic Therapy with Visudyne HS-031
- Oral Appliances for Obstructive Sleep Apnea HS-057
- Orthognathic Surgery HS-087
- Osteogenic Stimulation HS-019
- Outpatient Management of Preeclampsia HS-012
- Outpatient Pulmonary Rehabilitation HS-076
- Outpatient Rehabilitation Services HS-010
- Oxygen Use HS-088
- Panniculectomy HS-033
- PathFinderTG® Molecular Testing (Topographic Genotyping) HS-155
- Pediatric CPAP HS-099
- Pediatric Hearing Amplification HS-007
- Percutaneous Transluminal Angioplasty HS-051
- Peripheral Lymphedema Treatments HS-078
- PET Scan for Cardiac Applications HS 119
- PET Scan for Dementia and Neurodegenerative Disease HS-152
- PET Scan for Solid Tumors HS-112
- Pharmacogenomic Testing for Warfarin Response HS-130
- Phonophoresis HS-089
- PLAC Test for Prediction of Coronary Heart Disease and Ischemic Stroke HS-081
- Plantar Fasciitis Treatments HS-116
- Plasmin-Assisted Vitrectomy HS-122
- Postoperative Disposable Ambulatory Regional Anesthesia (PDARA) HS-011
- Progesterone for the Prevention of Preterm Birth in High-Risk Women HS-014
- Prolotherapy HS-073
- Prostate Px® Test for the Prediction of Recurrence of Prostate Cancer HS-156
- Proteomic-Based Testing for Ovarian Cancer (OvaCheck) HS-049
- Proton Beam Therapy HS-140
- Prothrombin Time Monitoring HS-025
- Pulse Oximetry for Home Use HS-171
- Seat Lift Mechanisms HS-166
- Sensory and Auditory Integration Therapy, Facilitated Communications HS-093
- Skilled Therapy Services-Florida HS-124
- Skilled Therapy Services-Georgia HS-018
- Skilled Therapy Services-Missouri HS-141
- Skilled Therapy Services-Ohio HS-030
- SpeechEasy Altered Auditory Feedback Devices for the Treatment of Stuttering HS-158
- Speech Generating Devices HS-024
- Spinal Cord Stimulation Implant HS-115
- Spinal Ultrasound HS-029
- Spinal Unloading Devices HS-145
- Stem Cell Transplantation HS-069
- Subtalar Implant HS-034
- Supprelin HS-020
- Surgery for Pectus Deformities (Pectus Excavatum and Pectus Carinatum) HS-177
- Telehealth (New York Medicaid) HS-149
- Terbutaline Pump for Preterm Labor HS-015
- Therapeutic Cooling Devices HS-139
- Topical Oxygen Wound Therapy HS-065
- Total Artificial Heart Devices HS-074
- Total Hip Resurfacing HS-082
- Transcranial Magnetic Stimulation HS-067
- Transcutaneous Electrical Joint Stimulation HS-098
- Transurethral Microwave Thermotherapy (TUMT) HS-044
- Transvaginal Ultrasound HS-120
- Treatment of Nausea and Vomiting in Pregnancy with Subcutaneous Pump HS-016
- Ultrasound Therapy for Wound Healing (Mist Therapy) HS-153
- Ultraviolet Light Therapy for Skin Conditions HS-174
- Urinary Incontinence Treatments HS-080
- Vacuum Assisted Socket System (VASS) HS-157
- Vagus Nerve Stimulation for Epilepsy HS-064
- Vagus Nerve Stimulation for Treatment-Resistant Depression HS-058
- Vantas Implant for the Treatment of Advanced Prostate Cancer HS-101
- Vertebral Axial Decompression Therapy (VAX-D) HS-047
- Video and Ambulatory EEG HS-005
- Virtual Colonoscopy HS-050
- Visual Evoked Potential Studies HS-102
- Voice Prosthesis HS-083
- Wearable and Automatic External Defibrillators HS-023
- Whole-Body CT Screening HS-097
- Wireless Capsule Endoscopy HS-104
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.
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