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Clinical Coverage Guidelines (CCGs) and Claims Edit Guidelines (CEGs)

Claims Edit Guidelines (CEGs)

Colorectal cancer is the third most common cancer diagnosed in men and women in the United States and accounts for approximately 50,630 deaths a year.

A patient in active treatment for substance use disorder (SUD) or monitoring across different phases of recovery may undergo medical management for a variety of medical conditions.

A study by Winner, et al.1 shows that long-acting reversible contraception (LARC) is more effective than other methods (e.g., pill, pact or ring). Risk of failure using oral contraceptive pills, transdermal patches or vaginal rings was 20 times higher than when using LARC.

The information contained within this policy will ensure that members receive care that is medically necessary and provided in the appropriate settings.

Healthcare providers utilize Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes to report medical services conducted on patients for accountability and reimbursement.

Prostate cancer is the second most common cancer in American men and the second leading cause of death (1 in 41 men).

This document serves as guidance to ensure that WellCare reimburses physicians and other health care professionals for the units billed without reimbursing for obvious billing submission, data entry errors or incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established Clinical Coverage Guidelines (CCGs) and other related guidelines, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.

A readmission occurs when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital, or hospital within the same network, within 30 days for symptoms related to, or for evaluation and management of, the prior stay’s medical condition.

Hawai'i Specific CCGs

Although acupuncture has been used for thousands of years in China and for decades in parts of Europe, it is a new agent of unknown use and efficacy in the United States.

Noninvasive ventilation has been used as a replacement for invasive ventilation, and its flexibility also allows it to be a valuable complement in patient management.

CAR-T (chimeric antigen receptor T) cells are a form of genetically modified autologous immunotherapy that can be directed at B cell precursor ALL.

A readmission occurs when a patient is discharged/transferred from an acute care Prospective Payment System (PPS) hospital, and is readmitted to the same acute care PPS hospital, or hospital within the same network, within 30 days for symptoms related to, or for evaluation and management of, the prior stay’s medical condition.

This testing is done to rule out, identify, or confirm a suspected genetic disorder in an affected individual. Diagnostic testing may be performed to help determine the course of the disease or choice of the relevant treatment.

Testing for drugs of abuse is performed to detect the use of prescription medications and illegal substances for the purpose of medical treatment.

The service teaches caregivers and enrollees to follow dietary specifications that are essential to the member’s health and physical functioning, to prepare and eat nutritionally appropriate meals and promote better health through improved nutrition.

Oral nutritional supplements are liquid or powders that can provide additional nutrients when combined with an oral diet for individuals with a functioning gastrointestinal tract.

The Peristeen® Anal Irrigation System is intended to instill water into the colon through a rectal catheter, which incorporates an inflatable balloon, inserted into the rectum to promote evacuation of the contents of the lower colon.

Physical therapy (PT) is the treatment of the complications and sequelae of a disease, or injury by the use of therapeutic exercise and other treatment modalities, that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, an individual's ability to go through the functional activities of daily living (ADL), and on reducing pain.

The health plan may implement directed quality improvement initiatives that require the coordination and use of community resources such as transportation services that may or may not be a component of the member’s benefit structure.

Post–acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and long-term care facilities.

Psychosocial rehab (PSR) encompasses community-based or clinic-based but community-focused services designed to assist adults in strengthening or regaining skills designed to help them achieve their self-determined rehabilitation goals in living, working, educational or social environments and the development of environmental supports necessary to thrive in the community with the least amount of professional intervention possible.

Clinical Coverage Guidelines (CCGs)


Acne vulgaris (acne) is the formation of comedones, papules, pustules, nodules, and/or cysts as a result of obstruction and inflammation of pilosebaceous units (hair follicles and their accompanying sebaceous gland).

Age-related macular degeneration (AMD) is a common eye condition and a leading cause of vision loss among people age 50 and older.

Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered.

Behavior analysis is a natural-science approach to understanding the behavior of individuals.

Aquatic therapy is an active therapeutic intervention that takes place in water.


Baha® devices are FDA-approved, bone-anchored, bone conduction hearing aids and, according to the FDA and manufacturer, are specifically indicated for patients over five years of age.

OnabotulinumtoxinA (Botox) injections have been found to be effective in individuals with a variety of medical conditions.

In 2010, over 207,000 new cases of breast cancer among women in the United States while 39,840 died from the disease.

The most common reason for breast reconstruction is to repair defects caused by breast cancer. Breast cancer is the second most frequently occurring cancer in the United States.

Johns Hopkins Health Library defines burns as a type of painful wound caused by thermal, electrical, chemical, or electromagnetic energy.


Chelation therapy is an established treatment for heavy metal poisoning.

The FDA assigns a special identifier number that corresponds to each device granted an investigational device exemption (IDE).

Although there are many definitions of clinical trials, they are generally considered to be biomedical or health-related research studies in human beings that follow a pre-defined protocol.

Diabetes mellitus is characterized by hyperglycemia due to impaired pancreatic insulin secretion or inefficient use of insulin by the body.

Cranial orthotic devices are used in infants for the treatment of positional plagiocephaly, deformation of the head that results from external pressure applied to the soft infant skull.

The American College of Physicians and the American Pain Society (ACP/APS) published a joint clinical guideline for the diagnosis and treatment of low back pain; spinal manipulation is recommended for patients who do not improve with self-care options.

Craniosynostosis is a condition in which the sutures close too early, causing problems with normal brain and skull growth.

Crisis Stabilization Unit Services is a facility-based program for members with urgent/emergent needs who require crisis stabilization services in a safe, structured setting.


Some medical conditions may result in a condition called lipoatrophy, characterized by facial wasting of fat under the skin of the face and other parts of the body.

Early identification of developmental disorders is critical to the well-being of children and their families. This is an integral function of the primary care medical home and an appropriate responsibility of all pediatric health care professionals.

Genetic testing can be performed for several reasons; predominantly among these reasons are 1) using genetic testing as a diagnostic tool, and 2) using testing as a mechanism for predicting the presence of a specific disease in those with a familial history.

Diaphragmatic/phrenic nerve stimulator devices are indicated for certain ventilator-dependent individuals who lack voluntary control of their diaphragm muscles to enable independent breathing without the assistance of a mechanical ventilator for at least four continuous hours a day.

The U.S. Food and Drug Administration (FDA) approved Duopa (a formula of carbidopa and levodopa) to treat a small subset of patients with advanced Parkinson’s disease.

A joint contracture is characterized by chronically reduced range of motion (ROM) secondary to structural changes in non-bony tissues including muscle, tendons, ligaments, and skin.


Evidence from the reviewed studies indicates that exhaled NO demonstrates moderate to good accuracy in diagnosing asthma and may be useful in predicting and monitoring inflammatory responses indicative of asthma exacerbation before and during anti-inflammatory treatment.

The FDA describes Duchenne muscular dystrophy (DMD) as a rare genetic disorder characterized by progressive muscle deterioration and weakness.

Sudden cardiac death (SCD) is typically defined as unanticipated death due to cardiac causes that occur within 1 hour of the onset of acute symptoms.


Uterine fibroids (or leiomyomas) are benign soft tissue neoplasms that arise from smooth muscle. These lesions can develop wherever smooth muscle is present, but malignant transformation probably does not occur.


Gender reassignment therapy, either as male-to-female transsexuals (transwomen) or as female-to-male transsexuals (transmen), consists of medical and surgical treatment that changes primary or secondary sex characteristics.

Genetic profiling of tumors allows breast cancers to be classified based on their expression of specific genes that are related to the clinical behavior of the disease.

Alzheimer’s disease (AD), which is the most common form of dementia, is a progressive, neurogenerative disorder characterized by amyloid plaques and neurofibrillary tangles in the brain.

Given that CF screening has been a routine part of reproductive care for women since 2001, it is prudent to determine if the patient has been previously screened before ordering CF screening that may be redundant.

Factor V Leiden is the name of a specific mutation that results in thrombophilia, or an increased tendency to form abnormal blood clots in blood vessels.

FAP and AFAP are inherited in an autosomal dominant manner. Approximately 75–80% of individuals with these conditions have an affected parent.

Fragile X syndrome is the most common cause of inherited mental retardation and is due to a mutation in the X-linked FMR1 gene.

Hereditary nonpolyposis colorectal cancer (HNPCC) is one of several familial syndromes that is associated with a high risk of colorectal adenocarcinoma.

Long QT syndrome (LQTS) is a disorder of the heart's electrical system. It is characterized by prolongation of the QT interval.

NF1 is inherited in an autosomal dominant fashion. In approximately one half of patients, the condition is caused by a new mutation in that conception.

Two major breast cancer predisposition genes, known as the breast cancer 1 susceptibility gene (BRCA1) and breast cancer 2 susceptibility gene (BRCA2), have been implicated in up to 40% of hereditary breast cancers, and it is estimated that mutations in BRCA1 and BRCA2 account for 5% to 10% of all breast cancers.

TSC is a variable multisystem disorder characterized by hamartomas that result in abnormalities of the skin (including hypomelanotic macules, facial angiofibromas, shagreen patches, fibrous facial plaques, and ungual fibromas), brain (including cortical tubers and subependymal nodules), kidneys (including angiomyolipomas and renal cysts), and heart (including rhabdomyomas and arrhythmias).

Growth Hormone Deficiency (GHD) is a rare disorder characterized by the inadequate secretion of growth hormone (GH) from the anterior pituitary gland, a small gland located at the base of the brain that is responsible for the production of several hormones.


Hearing aids are electronic amplifying devices designed to bring sound more effectively into the ear.

Social Security describes home health as a service furnished to an individual, by a home health agency, with a plan of care established and periodically reviewed by a physician, on a visiting basis in the individual’s place of residence.

Hyperbilirubinemia is the most common condition requiring medical attention in newborns.

Hyperbaric oxygen therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure.

Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive artificial airway (endotracheal tube or tracheostomy tube).


Hemophilia A, factor VIII deficiency, is a recessive X-chromosome linked inherited coagulation factor deficiency that result in a lifelong bleeding disorder.

The individual has engaged in an act of sexual abuse to another individual within the past 90 days (or more, if delay occurs due to delayed discovery or legal system.) or patient has a history of having committed a sexual offense, is in outpatient treatment, and is demonstrating behavior suggesting to the treating clinician that new offending behavior is imminent.


A study by Winner, et al. (2012) shows that long-acting reversible contraception (LARC) is more effective than other methods (e.g., pill, pact or ring).

On December 19, 2017 The US Food and Drug Administration (FDA) approved Luxturna (voretigene neparvovec-rzyl), a new gene therapy to treat a rare form of inherited vision loss that can lead to blindness.


Makena® (hydroxyprogesterone caproate injection) is a progestin medication indicated to reduce the risk of preterm birth in women with a singleton pregnancy who have a history of singleton spontaneous preterm birth.

The neonatal risks of late preterm (34 0/7 – 36 6/7 weeks of gestation) and early-term (37 0/7 – 38 6/7 weeks of gestation) births are well established.


NMES involves the use of a device which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.


Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.

Multiple sclerosis (MS) is an immune-mediated disease in which an abnormal response of the body’s immune system is directed against the central nervous system, brain, spinal cord and optic nerves.

Prostate cancer is the most common cancer among American males. An estimated 233,000 new cases were diagnosed in 2014 and 29,480 deaths resulted from prostate cancer.

The term "feeding disorder" refers to a condition in which a patient is unable or refuses to eat, or has difficulty eating, resulting in failure to grow normally.

Orthognathic surgery is the surgical correction of abnormalities of the mandible, maxilla, or both.

Of the estimated 5.6 million fractures that occur annually in the United States, approximately 5% to 10% will demonstrate signs of delayed or impaired healing.


Obstructive sleep apnea syndrome (OSAS) is a disorder of breathing in which prolonged partial upper airway obstruction and/or intermittent complete obstruction occurs during sleep disrupting normal ventilation and normal sleep patterns.

Amplification with hearing instruments should be considered for a child who demonstrates a significant hearing loss, including sensorineural, conductive, or mixed hearing losses of any degree.

Diabetes mellitus is characterized by hyperglycemia due to impaired pancreatic insulin secretion or inefficient use of insulin by the body.

Developmental disability is defined as an inability to perform age-appropriate functional skills as indicated by standard test scores less than 85, scaled score less than 7, percentile less than 16, Z-score less than −1.00 or developmental quotient (DQ) less than 80.2.

Post–acute care refers to a wide range of services, which include skilled nursing facilities, inpatient rehabilitation facilities, home health aides, outpatient physical and occupational therapy, and long-term care facilities.

Poteligeo® is considered medically necessary and a covered benefit for treatment of relapsed or refractory mycosis fungoides (MF) or Sezary syndrome (SS)

Prolastin-C is an Alpha1-Proteinase Inhibitor that is indicated for chronic augmentation and maintenance therapy in adults with clinical evidence of emphysema due to severe hereditary alpha1-antitrypsin deficiency.


On May 5, 2017 The U.S. Food and Drug Administration approved Radicava® (edaravone) as a treatment for patients with ALS.

On October 15, 2018, the United States Food and Drug Administration (FDA) approved Revcovi™ (elapegademaselvlr), a second-generation medication therapy for ADA.

Reduction mammoplasty is the surgical reduction of breast size. It was developed as a means of alleviating physical and emotional symptoms associated with excessive breast size and breast ptosis.

HP Acthar Gel is an adrenocorticotropic hormone (ACTH) analogue indicated as monotherapy for the treatment of infantile spasms in infants and children under 2 years of age.

Respite Care is short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home.

Beneficiaries may have a combination of developmental, neurological and medical conditions necessitating the need for certain dental services to be provided in an operating room as an outpatient hospital service.


Fecal incontinence is defined as the involuntary loss of solid or liquid feces.

SBIRT (Screening Brief Intervention Referral to Treatment) is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.

Speech therapy is the study, diagnosis and treatment of speech, language and communication in people of all ages to enable them to communicate to the best of their ability.

Spinal Muscular Atrophy (SMA) disorders are characterized by degeneration of the anterior horn cells in the spinal cord and motor nuclei in the lower brainstem.

Stem-cell transplantation refers to the transplantation of hematopoietic stem cells (HSCs) into a patient.


Targeted Case Management Services (TCM) are direct outpatient services delivered in the member’s home, residence of another type, or within a community setting.

Telehealth and telemedicine are often used interchangeably; WellCare uses the following distinction

Implantable testosterone pellets may be indicated as second-line testosterone replacement therapy for males.

Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior.

DiGeorge syndrome (DGS) is a disorder in which there is a defect in the development of the pharyngeal pouch system. The syndrome is most commonly caused by a chromosomal deletion at 22q11.2.

The health plan may implement directed quality improvement initiatives that require the coordination and use of community resources such as transportation services that may or may not be a component of the member’s benefit structure.

Nausea and vomiting of pregnancy, commonly known as “morning sickness,” affects approximately 80 percent of pregnant women.

Lymphedema is an accumulation of lymphatic fluid in the interstitial tissue, principally in the subcutaneous fatty issues.

Trogarzo™ (ibalizumab) is a humanized monoclonal antibody developed for the treatment of multidrug resistant HIV-1 infection.


Psychological testing is a covered benefit in accordance with the member’s benefit plan, and when indicated the WellCare, Inc.


VANTAS® (histrelin implant) is a sterile, non-biodegradable, diffusion-controlled HYDRON® polymer reservoir containing histrelin acetate, a synthetic nonapeptide analog of the naturally occurring gonadotropin releasing hormone (GnRH), also known as luteinizing hormone releasing hormone (LH-RH), possessing a greater potency than the natural sequence hormone.


Wound care includes, but is not limited to ulcers, pressure ulcers, open surgical sites, fistulas, tube sites and tumor erosion sites when the skills of a licensed therapist, qualified wound care nurse, nurse or physician/physician extender are required to safely and effectively provide the care necessary for their treatment.


Each year in the United States, more than 30,000 patients undergo back surgery for lumbar spinal stenosis, an abnormal narrowing or constriction of spaces in the back that provide pathways for spinal nerves.


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Last Updated On: 1/8/2019