Skip to main content

Clinical Policies

Size

For our Wellcare members, we provide transparent access to medical Clinical Policies which detail the services and procedures coded as medically necessary, cosmetic, or experimental.

Please note that the current policy list is not exhaustive, but rather a collection of policies that individuals have expressed an interest in viewing. Amendments, modifications, supplements to these posted policies and/or additional policies may be posted in the near future.

Wellcare shares information about services that require authorization. Clinical guidelines that Wellcare uses to determine the medical necessity of services that require authorization in our Medicare lines of business can be viewed below. If a policy does not exist on that page, additional guidelines can be accessed by members in the Member Portal and providers in the Provider Portal. New users who are current members and providers of Wellcare can request log-in credentials by clicking those links. 

Prospective members and providers who do not have the ability to create a portal account with Wellcare can also request access to specific guidelines by sending an email to Clinical-Guidelines@wellcare.com, and include your name, and if you are a prospective member or provider. 

Access Wellcare MCG Guidelines

Medicare Clinical Policies

A

Acupuncture involves the manual and/or electrical stimulation of thin, solid, metallic needles inserted into the skin.

Attention deficit hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders in children, with an increasing prevalence of diagnosis in adults.

Fixed wing (FW) or rotary wing (RW) air ambulance are furnished when the medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.

Ambulatory surgery centers (ASC) operate for the purpose of offering outpatient surgical services to members/enrollees in an environment appropriate for low risk procedures on members/enrollees with low risk health status.

Cartilage transfer procedures include autologous chondrocyte implantation, osteochondral allograft transplantation (OAG or OCA) [i.e., including repair of anterior cruciate ligament and meniscus], and osteochondral autograft transplantation [mosaicplasty, Osteochondral Autograft Transplantation System (OATS)].

Diagnostic infertility services to determine the cause of infertility and treatment are covered only when specific coverage is provided under the terms of a member’s/enrollee’s benefit plan.

This policy describes the medical necessity requirements for allogeneic hematopoietic cell transplants for sickle cell anemia and β–thalassemia

B

There are two categories of bariatric surgery: restrictive procedures and malabsorptive procedures.

Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions

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.

C

The release of cardiac biomarkers is among the cascade of events that occur during acute coronary syndromes and cardiac ischemia

Epidural steroid injections have been used for pain control in patients with radiculopathy, spinal stenosis, and nonspecific low back pain, despite inconsistent results as well as heterogeneous populations and interventions in randomized trials.

"Medical necessity guidelines for routine costs of clinical trials in accordance with Centers for Medicare & Medicaid (CMS) and the Patient Protection and Affordable Care Act (PPACA) requirements.

This policy outlines medical necessity criteria for the replacement of cochlear implants and/or cochlear implant components.

This policy will provide general guidelines as to when cosmetic and reconstructive surgery is or is not medically necessary.

D

Medical necessity guidelines for dental anesthesia in the inpatient or ambulatory surgery setting

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.

Electroencephalography (EEG) is a significant component of epilepsy diagnosis

DME is defined as equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation and they involve removal of the portion of the intervertebral disc compressing the nerve root or spinal cord (or both) with or without the aid of a headlight loupe or microscope magnification.

This policy describes the medical necessity requirements for a donor lymphocyte infusion (DLI).

Urine drug testing is a key diagnostic and therapeutic tool that is useful for patient care and monitoring of adherence to a controlled substance treatment regimen and to identify drug misuse or addiction prior to starting or during treatment with controlled substances.

E

This policy describes the medically necessary indications for neurophysiologic evoked potentials.

This policy outlines general guidelines to use in determining coverage of experimental or investigational, or potentially experimental or investigational medical and behavioral health technologies.

An electroencephalogram (EEG) is a non-invasive method for assessing neurophysiological function.

Electric tumor treating fields (TTF), also known as alternating electric field therapy, are used for the treatment of glioblastoma, and are delivered by Optune® (NovoCureTM), a portable medical device that generates low-intensity electric fields termed Tumor Treating Fields.

F

Chronic low back pain is frequently attributed to disorders of the facet joint.

Fecal incontinence defined as the uncontrolled passage of feces or gas over at least 1 month’s duration, in an individual of at least four years of age, who had previously achieved control.

FerriScan® R2-MRI is a magnetic resonance imaging (MRI)-based solution for measuring liver iron concentration (LIC) in patients with iron overload.

Male and female fertility may be transiently or permanently affected by medical treatments such as gonadotoxic therapy, cytotoxic chemotherapy, or radiation therapy, as well as by other iatrogenic causes.

This policy describes the medical necessity requirements for performing fetal surgery. This becomes an option when it is predicted that the fetus will not live long enough to survive delivery or after birth.

Functional magnetic resonance imaging (fMRI) is an imaging procedure in which an MRI is used to localize regions of activity in the brain by measuring blood flow and/or metabolism following task activation.

G

Gastric electrical stimulation (GES) has been used in patients who are proven refractory to conventional treatment for gastroparesis.

Services for gender affirmation most often include hormone treatment, counseling, psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction.

Multiplex molecular panels allow for the qualitative detection of nucleic acid from multiple viral, parasitic, and bacterial pathogens in stool samples from those with symptoms of gastroenteritis or infectious colitis.

H

Heart-lung transplantation is treatment of choice for patients with both end-stage heart and endstage lung disease

This policy provides medical necessity guidelines for Holter monitoring up to 48 hours.

A planned home birth is an elective alternative to delivery in a birthing center or hospital setting.

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

Homocysteine is a nonproteinogenic amino acid generated during the conversion of methionine to cysteine.

Hospice is a coordinated, integrated program developed by a multidisciplinary team of professionals to provide end-of-life care primarily focused on relieving pain and symptoms specifically related to the terminal diagnosis of members/enrollees with a life expectancy of six months or less.

Helicobacter pylori (H. pylori) is the most prevalent chronic bacterial infection and is associated with peptic ulcer disease, chronic gastritis, gastric adenocarcinoma, and gastric mucosa associated lymphoid tissue (MALT) lymphoma

Hyperemesis gravidarum is a term reserved to describe the most severe cases of nausea and vomiting in pregnancy (NVP) which results in the inability to rehydrate and replenish nutritional reserves.

Hyperhidrosis is defined as excessive sweating beyond a level required to maintain normal body temperature in response to heat exposure or exercise.

I

Hypoglossal nerve stimulation, also referred to as an upper airway stimulation (UAS) system, is proposed as a treatment strategy for select patients with moderate to severe obstructive sleep apnea (OSA).

An implantable, intrathecal drug delivery system consists of an implanted pump and catheter that delivers a drug directly into the spinal fluid.

The implanted device measures and monitors daily pulmonary artery (PA) pressure. The data is used by physicians for heart failure management with the goal of reducing heart failure hospitalizations.

Inhaled nitric oxide (iNO) is a selective pulmonary vasodilator in which its mechanism of action results in smooth muscle relaxation.

Medical necessity criteria for intensity-modulated radiotherapy (IMRT). IMRT is an advanced form of 3-dimensional (3-D) conformal radiation therapy that delivers a more precise radiation dose

This policy describes the medical necessity criteria for the review of intestinal and multivisceral transplant requests.

Intradiscal steroid injections involve injecting glucocorticoids directly into the spinal disc that has been identified as the source of pain.

L

Targeted phototherapy utilizes non-ionizing ultraviolet radiation with therapeutic benefit.

Nursing home care includes both long term residential care and short-term post-acute or rehabilitative care. This policy addresses long term care (LTC) placement ranging from basic custodial care to more intense care needed due to dementia or other complex medical needs.

Low-frequency ultrasound debridement is a noncontact debridement method that provides simultaneous cleansing and debridement of wounds.

Medical necessity criteria for the review of lung transplantation requests.

M

This policy addresses when measurement of 1,25(OH)2D is appropriate and medically necessary.

Mechanical stretching devices are used for the prevention and treatment of joint contractures of the extremities, with the goal to maintain or restore range of motion (ROM) to the joint.

Multiple Sleep Latency Testing (MSLT) objectively measures an individual’s tendency to fall asleep and is a component of the routine evaluation for suspected narcolepsy or idiopathic hypersomnia.

N

Maternal drug use and intrauterine exposure of the fetus during pregnancy can lead to drug withdrawal in the infant after delivery. Clinically important neonatal withdrawal most commonly results from intrauterine opioid exposure.

Through the increased incidence of intra-partum antibiotics, early-onset neonatal sepsis is occurring less frequently.

Nerve blocks are the temporary interruption of conduction of impulses in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions.

Allogeneic hematopoietic stem cell transplants that do not destroy all of the hematopoietic cells in the bone marrow are termed reduced-intensity or nonmyeloablative conditioning regimens.

This policy describes the medical necessity requirements for Neuromuscular Electrical Stimulation (NMES); also known as Functional Electrical Stimulation [FES] when used for walking in SCI patients).

This policy will provide general guidelines as to when non-invasive home ventilators are or are not medically necessary.

O

Medical necessity criteria for obstetrical home health programs offered by vendors such as Optum.

Cell-free circulating tumor DNA (ctDNA) originates directly from the tumor tissue (primary or metastasis); as tumor cells die the contents are released into the bloodstream.

Optic nerve (ON) sheath decompression involves direct decompression (fenestration) of the ON sheaths just behind the globe. The approach and technique for an ON sheath fenestration varies.

This policy describes the medical necessity requirements for orthognathic surgery.

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.

Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxemia

P

This policy describes the medical necessity requirements for pancreas transplantation procedures.

Panniculectomy is the surgical removal of a panniculus or excess skin and adipose tissue that hangs down over the genital and/or thigh area causing difficulty in personal hygiene, walking, and other physical activity.

Medical necessity criteria for multiplex respiratory polymerase chain reaction (PCR) testing.

Pediatric heart disease may be a progressive disease, affecting cardiac structure and function in infants and children.

End stage liver disease presents unique clinical considerations in the pediatric population.

Posterior tibial nerve stimulation (PTNS), also known as peripheral tibial nerve stimulation2 , is a minimally invasive form of electrical neuromodulation used to treat overactive bladder (OAB) syndrome and associated symptoms of urinary urgency, urinary frequency, and urge urinary incontinence.

Goals of oral function therapy are to identify the child’s optimal feeding methods, maximize safety and avoid the risk of medical complications and help the child achieve age appropriate functional skills.

Atrial fibrillation (AF) is the most commonly encountered sustained tachyarrhythmia and is associated with a 5-fold increased risk of stroke, and stroke risk increases with age.

To provide guidelines for the authorization of outpatient or home care speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services. Initial evaluation requirements are based on the individual benefit contract.

Proton beam therapy (PBT) is a form of external beam radiation therapy (EBRT) that utilizes protons (positively charged subatomic particles) to precisely target a specific tissue mass.

R

Medical necessity criteria for radiofrequency ablation of uterine fibroids.

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.

Medical necessity guidelines for repair of nasal valve compromise.

S

Sacroiliac joint (SIJ) fusion, or arthrodesis, is a surgical technique that fuses the iliac bone to the sacrum for stabilization.

Description Treatment for sacroiliac joint (SIJ) dysfunction is usually conservative (non-surgical) and focuses on trying to restore normal motion in the joint.

Sclerotherapy is a minimally invasive procedure to diminish abnormally dilated and symptomatic veins.

Selective dorsal rhizotomy (SDR) is a neurosurgical technique developed to reduce spasticity and improve mobility in children with cerebral palsy (CP) and lower extremity spasticity

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

There are currently a wide variety of bioengineered products available for soft tissue coverage to affect closure.

Criteria for skilled nursing facility (SNF) levels of care, to be used in conjunction with general SNF placement criteria in InterQual®.

Transforaminal epidural steroid injections (TFESIs) and selective nerve root blocks (SNRBs) are alternatives to interlaminar epidural steroid injections for the treatment of radicular pain.

Peripheral nerve stimulation (PNS) is intended to decrease chronic and acute pain by stimulating peripheral nerves with leads placed adjacent or parallel to the affected nerve.

T

A tandem transplant, (also known as a sequential or double transplant), refers to a planned second course of high-dose therapy and stem cell transplant (SCT) within 6 months.

The purpose of this policy is to define medical necessity criteria for the diagnostic evaluation of vaginitis (excluding Trichomonas vaginalis, vaginal pH testing, and microscopic examination with saline and KOH) in members/enrollees ≥ 13 years of age.

Numerous essential metabolic functions are mitigated by hormones produced by, and affecting the thyroid

The SynCardia temporary Total Artificial Heart (TAH) (SynCardia Systems Inc.), formerly known as the CardioWest Total Artificial Heart, is a biventricular pulsatile pump that replaces the patient’s native ventricles and valves.

This policy describes the medical necessity requirements for two types of PN, (A) total parenteral nutrition (TPN), in which all of the necessary macronutrients and micronutrients are supplied to the patient, and (B) intradialytic parenteral nutrition (IDPN), in which nutrition is supplied to end-stage renal disease (ESRD) patients undergoing dialysis as an alternative to regularly scheduled TPN.

Trigger points cause pain at their physical location as well as referred pain to other areas in a specific pattern.

To provide guidelines for the authorization of outpatient or home care speech therapy, occupational therapy, and/or physical therapy evaluation and treatment services.

U

This policy outlines the medical necessity criteria for ultrasound use in pregnancy. Ultrasound is the most common fetal imaging tool used today.

Sacral neuromodulation (SNM) or sacral nerve stimulation (SNS) refers to stimulation of nerves that innervate the bladder and pelvic floor to treat lower urinary tract dysfunction.

Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction.

V

Vagus nerve stimulation (VNS) has been used in the treatment of epilepsy and has been studied for the treatment of refractory depression and other indications.

A ventricular assist device (VAD) is a mechanical pump that helps the heart when it is too weak to pump blood through the body. VADs are designed to enhance blood flow to the bodily organs, either in conjunction with, or as a replacement for, a damaged or diseased heart.

A global consensus statement recommends against universal screening for vitamin D deficiency in healthy children as there is insufficient evidence that the potential benefits of testing outweigh the potential harms

W

It is the policy of health plans affiliated with Centene Corporation® that special wheelchair seating cushions are medically necessary for certain indications.

The wireless motility capsule (WMC) assesses gastroparesis or delayed gastric emptying

Contact Us icon

Need help? We're here for you.

Contact Us
Y0020_WCM_134133E_M Last Updated On: 10/1/2023