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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.

The AHRQ funds three Centers which focus on the delivery of preventive services in clinical settings. Each one is conducting three research projects seeking solutions to the problems of underuse, overuse, and disparities in use of preventive services.

The QI Program reflects a continuous quality improvement (CQI) philosophy and mode of action.

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.

Generalized anxiety disorder (GAD) and panic disorder (PD) are two common mental disorders in the United States.

Autism spectrum disorder (ASD) is a developmental disorder characterized by persistent and significant impairments in social interaction and communication and restrictive and repetitive behaviors and activities, when these symptoms cannot be accounted for by another condition.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the treatment of behavioral health conditions and substance use disorders (SUDs) in high risk pregnancy.

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.

The challenge of ensuring that children and adolescents receive evidence based mental health treatment requires a multi-pronged approach where children and families access and accept treatment, providers gain the necessary skills/knowledge and organizations and funding policies align to support them.

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).

Gender Dysphoria (GD) is defined by the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5™) as a condition characterized by the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender also known as “natal gender”, which is the individual’s sex determined at birth.

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 practice recommendations for the treatment of Post-Traumatic Stress Disorder (PTSD).

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.

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

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

Deaths due to drug overdose have risen over the past two decades; nationally it has become the leading cause of injury death in the United States.

Chronic, Preventive, and Other CPGs

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.

Preventive health service can help detect disease earlier to allow optimal treatment and live longer.

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.

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.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the treatment of Cardiovascular Disease, as well as Cerebrovascular Disease, Peripheral Artery and Aortic Atherosclerosis.

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.

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.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based recommendations for dental and oral health. Dental caries (cavities) is one of the most common, preventable childhood diseases. Regular dental visits provide access to cleaning, early diagnosis and treatment, as well as education about caring for teeth to prevent problems. Approximately 25 percent of the nation’s children have nearly 80 percent of cavities, and tooth decay is the major cause of tooth loss in children. Each year, Americans make about 500 million visits to the dentist.

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.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the diagnosis, treatment and management of epilepsy for children and adults.

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.

Frailty indicators are important for care management not only among older adults, but also for many types of chronically ill persons, even at younger ages.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the diagnosis and treatment of Hepatitis.

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.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the management of skin infections (including cellulitis) and the prevention and management of sepsis.

Infant mortality is defined as the death of an infant before his or her first birthday. The infant mortality rate is the number of infant deaths for every 1,000 live births.

Neurodegenerative diseases occur when nerve cells in the brain or peripheral nervous system lose function over time and deteriorate.

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.

Obesity is a serious health issue in the United States – over a third of the population is obese. This can lead to preventable conditions like heart disease, stroke, type 2 diabetes, and certain cancers.

Preventive health service can help detect disease earlier to allow optimal treatment and live longer. Providers and those working with Members should emphasize counseling on such topics such as quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use.

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

Pain is cited as the most common reason Americans seek health care and is a major contributor to health care costs.

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.

The objective of this Clinical Practice Guideline (CPG) is to provide evidence-based practice recommendations for the management of pneumonia including the prevention and management of sepsis.

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.

Pregnancy which is confirmed by a blood test, ultrasound, detection of fetal heartbeat or an X-ray has a full-term duration of 40 weeks and is measured from the date of the woman’s last menstrual period (LMP).

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.

A traumatic brain injury (TBI) is caused by a bump, blow, or jolt to the head that disrupts the normal function of the brain.

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.

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Last Updated On: 6/19/2018