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Clinical Practice Guidelines

Clinical Practice Guidelines are best-practice recommendations based on available clinical outcome and scientific evidence. WellCare Clinical Practice Guidelines reference expert professional and clinical society recommendations, ensuring that the guidelines contain the highest level of evidence-based content. Clinical Practice Guidelines are also used to guide efforts to improvement the quality of care in our membership.

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.

CPG Hierarchy

While clinical judgment may supersede the CPGs, the guidelines aid Providers with guidelines centered on procedures, pre-appraised resources and informational tools to assist in applying evidence from research in the care of individual members and populations.

Behavioral Health

Attention Deficit Hyperactivity Disorder is a neurobehavioral disorder of children, adolescents and adults characterized by persistent pattern of difficulty paying attention, excessive activity, and impulsivity that interferes with or reduces the quality of cognitive, academic, social, emotional, behavioral or occupational functioning.

Antipsychotic prescribing for children has increased rapidly in recent decades, driven by new prescriptions and by longer duration of use.

Sexual violence is defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion, by any person regardless of their relationship to the victim, in any setting, including but not limited to home and work.”

Risk assessment is the use of various tools or instruments typically based on scientific evidence, to estimate an offenders’ potential for reoffending or causing harm to others and potential causes or sources of that risk.

Two serious conditions of pregnancy include placenta previa (when the placenta lies near or over the cervix) and placenta abruption (when the placenta separates from the uterus).

The purpose of this guideline is to assist primary care in developing systems that support effective assessment, diagnosis and ongoing management of initial and recurrent major depression and persistent depressive disorder in adults age 18 and over, and assist patients to achieve remission of symptoms, reduce relapse and return to previous level of functioning.

Bipolar affective disorder, or manic-depressive illness (MDI), is a common, severe, and persistent mental illness.

This practice parameter describes the epidemiology, clinical picture, differential diagnosis, course, risk factors, and pharmacological and psychotherapy treatments of children and adolescents with major depressive or dysthymic disorders.

WellCare adheres to InterQual criteria and the guidance of the American Psychiatric Association (APA) in determining the treatment needs of members with eating disorders (ED).

Major depressive disorder has significant potential morbidity and mortality, contributing to suicide, incidence and adverse outcomes of medical illness, disruption in interpersonal relationships, substance abuse, and lost work time.

Persons with serious mental illness (SMI) are now dying 25 years earlier than the general population. Their increased morbidity and mortality are largely due to treatable medical conditions that are caused by modifiable risk factors such as smoking, obesity, substance abuse, and inadequate access to medical care.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based recommendations for the use of psychotropic medication in children and adolescents.

These trials point to a reconsideration of treatment with the antipsychotics perphenazine and molindone and by extension other first-generation antipsychotics, with the possible exception of haloperidol, for which some trials have shown greater rates of extrapyramidal side effects or less favorable clinical response.

WellCare endorses the use of Screening Brief Intervention Referral to Treatment (SBIRT) for appropriate populations in Medicaid.

Specific substance use disorders are outlined below as defined by the American Psychiatric Association (APA).

Substance users may not seek prenatal care because of fear, guilt and shame. In addition, there may be concerns about medical and legal intervention.

Suicide ranks as the 10th leading cause of death in the United States; globally, an estimated 700,000 people take their own lives annually.

Chronic, Preventive, and Other CPGs

All members should visit their physician on a regular basis. A baseline physical exam visit should occur for all new non-pregnant adult members regardless of age, within the first 90 days of enrollment.

Clinicians should obtain long-term assessments of cognition whenever possible to gain evidence of progressive decline.

Asthma is a chronic inflammatory disease of the airways. In those susceptible to asthma, this inflammation causes the airways to spasm and swell periodically so that the airways narrow.

Screening tests are available for breast, cervical, colorectal, lung, ovarian, prostate and skin cancers.

Cholesterol deposits in the arteries further narrow the ability of blood flow easily. To compensate for the additional force needed to pump blood, the heart gets thicker and enlarges.

Chronic kidney disease is defined as a glomerular filtration rate or GFR <60 mL/min/1.73m2 for >3 months with or without kidney damage.

Heart failure (HF) is a major and growing public health problem in the United States. Approximately 5 million Americans have heart failure and there will be approximately 550,000 new cases of heart failure each year.

Chronic obstructive pulmonary disease (COPD) is a slowly progressive lung disease involving the airways and/or pulmonary parenchyma, resulting in a gradual loss of lung function.

Heart and blood vessel disease — cardiovascular disease, also called heart disease — includes numerous problems, many of which are related to a process called atherosclerosis.

Diabetes mellitus (DM) is a group of metabolic diseases in which a person has high blood sugar. This high blood sugar produces the symptoms of frequent urination, increased thirst, and increased hunger.

Diabetes mellitus (DM) is a group of metabolic diseases in which a person has high blood sugar. This high blood sugar produces the symptoms of frequent urination, increased thirst, and increased hunger.

Annually, 1 in 3 adults over the age of 65 falls in the United States, causing moderate to severe injuries, such as hip fractures and head injuries; such injuries can increase the risk of early death.

Readiness of the patient for treatment should be considered prior to initiating ART. ART should be recommended and offered regardless of CD4 cell count.

Infection with human immunodeficiency virus (HIV) produces a spectrum of disease that progresses from a clinically latent or asymptomatic state to acquired immunodeficiency syndrome (AIDS) as a late manifestation.

High blood pressure is a common condition in which the force of the blood against artery walls is high enough that it may eventually cause health problems, such as heart disease.

Acute low back pain (LBP) with or without radiculopathy is one of the most common health problems in the United States and is the leading cause of disability for persons younger than age 45.

Approximately 250,000 U.S. children aged 1-5 years have blood lead levels greater than 10 micrograms of lead per deciliter of blood, the level at which the Centers for Disease Control and Prevention (CDC) recommends public health actions be initiated.

Motivational interviewing (MI) is a proven patient-centered counseling method for addressing patient ambivalence and resistance to change regarding health behaviors.

The prevalence of obesity is reaching epidemic proportions. Obesity is a risk factor for Type 2 diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, cerebrovascular disease, and osteoarthritis.

Since 1980, obesity rates have nearly tripled - approximately 12.5 million American adolescents aged 2-19 years are obese with significant disparities among Hispanic boys and non-Hispanic Black girls.

Osteoporosis is a disease characterized by low bone mass and loss of bone tissue that may lead to weak and fragile bones.

Palliative Care is patient and family-centered health care that focuses on effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient / family needs, values, beliefs, and cultures.

This schedule includes recommendations in effect as of January 1, 2015. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible.

Sore throat is a common chief complaint of adults treated in outpatient settings. Although its differential diagnosis is large and includes other causes important to recognize, the majority of immunocompetent adults presenting with sore throat have acute infectious pharyngitis.

Postpartum care is equally important - early infancy is a critical time for the health of both baby and mother; continuity of care can help detect problems early and prevent complications.

Preconception care is a critical component of health care for women of reproductive age and efforts to improve pregnancy outcomes should begin before any pregnancy.

Early, effective prenatal care can identify mothers at risk of delivering a preterm or growth-retarded infant and provide an array of medical and educational interventions.

Rheumatoid arthritis (RA) is an autoimmune disorder of unknown etiology characterized by symmetric, erosive synovitis and, in some cases, extraarticular involvement.

Sickle cell disease is a genetic disorder that affects the body’s red blood cells. In this disease, defective hemoglobin (a substance that carries oxygen in the blood) causes the red blood cells to change shape (into a sickle) when oxygen is released to tissues.

The most common cause of chemical dependence in the United States is nicotine. Nicotine addiction means that an individual is dependent on nicotine – nicotine can be found in cigarettes or smokeless tobacco.

Transitions of care (TOC) involves the movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.


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Last Updated On: 9/23/2015