Skip to Main Content

Effective February 6, 2027: Clinical Policies

Date: 10/30/26

Wellcare By Allwell and Wellcare By Superior HealthPlan (Duals) has updated certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result, the following policies are effective on February 6, 2027, at 12:00 AM.

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Allogeneic Hematopoietic Progenitor Cell Therapy

(MC.CP.MP.249)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Updated Description section to include TREGZI
  • Added Criteria III. to include medically necessary criteria for TREGZI
  • Background and reference list updated to include TREGZI information to align with updated criteria

Cosmetic and Reconstructive Procedures

(MC.CP.MP.31)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Annual review
  • Combined I. and A
  • Removed I.A.1-I.A.3
  • Added CPT codes 54163, 54360, 54380, 54385, and 54390 to policy

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

(MC.CP.MP.107)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Annual review
  • Removed section titled Breast Prosthetics along with applicable HCPCS codes L8030, L8035

Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy

(MC.CP.MP.250)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Annual review
  • Coding and description reviewed

Medical Necessity Criteria

(MC.CP.CPC.05)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Annual review
  • Clarified InterQual "platform" in section B. of Policy/Criteria
  • Removed note to see CP.MP.36 under definition A. Removed "and not investigational" from D. under Definitions
  • Removed sections E. and F. under Definitions
  • Revised section A. to note that LCAs may be consulted with interpret billing, coding or implementation requirements associated with applicable CMS guidance
  • Revised section of A. referencing criteria sources used when full coverage criteria do not exist from D-F to B-D
  • Revised section B. to specify internally developed Centene clinical polices approved by the UM committee
  • Removed section 3 from C. Experimental and/or investigational technologies
  • Updated all section D. Not medically necessary verbiage

Sacoiliac Joint Interventions for Pain Management

(MC.CP.MP.166)

Wellcare By Allwell (Medicare) and Wellcare By Superior HealthPlan (Duals)

Policy updates include:

  • Annual review
  • In V., removed “on a case-by-case basis” and criterion D. regarding notification of primary care provider
  • Coding reviewed and updated

To review all policies, please visit Medicare Prior Authorization Medical Clinical Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Medicare Quality Committee.

For questions or additional information, please contact Provider Services at: