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Clinical Coverage Guidelines (CCGs)

Claims Edit Guidelines (CEGs)

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.

Nebraska Specific CCG


Medical abortion, which involves the use of medications rather than a surgical procedure to induce an abortion, is an option for women who wish to terminate a first-trimester pregnancy.

In late 2019, 2019-Novel Coronavirus (COVID-19) caused severe pneumonia cases clustered in Wuhan, China, and spread rapidly

Hearing aids, hearing aid repairs, hearing aid rental, assistive listening devices and the necessary batteries and supplies are covered when the services are medically necessary, ordered by a physician and authorized by Medicaid.

A doula is a certified professional trained to provide physical, emotional, and informational support to expectant mothers throughout their pregnancy, delivery, and post-partum period.

Clinical Coverage Guidelines (CCGs)

A

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).

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.

B

There is sufficient evidence in peer-reviewed medical literature to support the use of bariatric surgeries for the clinically obese individual.

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.

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.

C

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.

Craniofacial surgery encompasses a broad spectrum of reconstructive procedures of the cranium and face. The objectives of these procedures are to correct deformities of the face and skull bones that result from birth defects, trauma, or disease and to restore craniofacial form and function by medical and surgical means.

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.

D

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.

E

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.

F

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.

G

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.

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.

H

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).

J

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.

L

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.

M

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.

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

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.

N

Diagnostic Testing Guidelines for 2019 Novel Coronavirus HS-326

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

O

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.

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.

P

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.

The individualized assessment of the risk-benefit balance is central to decision making regarding pharmacotherapy for stroke reduction in AF.

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.

R

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

The Acessa™ Procedure is a minimally invasive, uterine sparing, outpatient treatment for fibroids found within the uterine wall. Using radiofrequency ablation to destroy each fibroid by applying controlled energy through a small needle, the Acessa™ Procedure does not affect surrounding tissues and multiple fibroids can be treated though a single laparoscopic uterine puncture.

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.

S

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.

Varicose veins can cause significant pain and discomfort, superficial thrombophlebitis, bleeding, and ulceration.

Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.

According to the Centers for Medicare & Medicaid Services (CMS), chronic wounds of the lower extremities, including venous stasis ulcers (VSU), venous leg ulcers (VLU), Diabetic foot ulcers (DFU) and pressure sores, are a major public health problem.

Soliris® (eculizumab) is a complement inhibitor which inhibits the terminal part of the complement cascade, a part of the immune system that, when activated in an uncontrolled manner, plays a role in serious rare disorders like paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome (aHUS) and anti-acetylcholine receptor (AchR) antibody-positive myasthenia gravis (MG).

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.

T

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.

U

Paroxysmal nocturnal hemoglobinuria (PNH) is a rare hematopoietic stem cell disorder of the X chromosome. It is estimated that there are as many as 1 to 10 cases per million, however, it is thought that many cases go undiagnosed.

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

V

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.

W

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.

X

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: 5/24/2021
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