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Effective April 20, 2026: Clinical Policies

Date: 01/20/26

Wellcare By Allwell has approved 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 April 20, 2026, at 12:00AM.

Policy

Applicable Products

New Policy Overview or Updated Policy Revisions

Facility-based Sleep Studies for Obstructive Sleep Apnea

(MC.CP.MP.248)

Wellcare By Allwell (Medicare)

Policy Updates Include:

  • Description updated to include titration polysomnography (PSG) for hypoglossal nerve stimulation (HNS)
  • Added Criteria IV. to include titration PSG for HNS
  • Added “Medicare” verbiage throughout criteria for clarification
  • Background updated to include information regarding titration PSG for HNS

Outpatient Oxygen Use

(MC.CP.MP.190)

Wellcare By Allwell (Medicare)

Policy Updates Include:

  • Updated verbiage in Criteria I.B. regarding Group I and Group II hypoxemia for clarity
  • Updated verbiage in Criteria I.B.1.c. regarding symptoms and signs and examples for clarity
  • Updated verbiage to include “supplemental” oxygen in Criteria I.B.1.d. for clarity
  • Coding updated to include E0446 and updated

Skin and Soft Tissue Substitutes for Chronic Wounds

(MC.CP.MP.185)

Wellcare By Allwell (Medicare)

Policy Updates Include:

  • Added “up to four initial applications of” to policy statement I
  • Added medically necessary product types for DFU in I.F.1.d. and for VLU in  I.F.2.d
  • In I.G., removed that applications should not exceed 10 and the note regarding coding tables
  • In I.H., noted that up to four applications are initially approved, up to a total of eight
  • Added requirements in I.I and I.J
  • Added section II and moved section II. non-medically necessary criteria under section III
  • Updated background with evidence for specific product types
  • Updated coding tables to reflect medically necessary product types for DFU and VLU, and those considered not medically necessary for either
  • Title changed to “Skin and Soft Tissue Substitutes for Diabetic Foot Ulcers and Venous Leg Ulcers”
  • Specified that policy statements I. and III. apply to DFU and VLU
  • Removed full-thickness skin loss ulcers as an indication in I.F.3

Transplant Service Documentation Requirements

(MC.CP.MP.247)

Wellcare By Allwell (Medicare)

Policy Updates Include:

  • Added note to policy description stating "This policy notes documentation requirements only for solid organ and stem cell transplant requests. Please refer to plan-approved medical necessity criteria for solid organ and stem cell transplant requests”
  • Updated verbiage in Criteria I., Criteria I.A.2., and Criteria I.B.4. for clarity
  • Changed criteria I.A.2.a.-c. into a note
  • Verbiage updated in Criteria I.B.6. for clarity
  • Updated verbiage in Criteria I.B.7. to “breast cancer screening”, “cervical cancer screening,” and “colon cancer screening”
  • Updated verbiage in Criteria I.B.10., I.B.10.f., and I.B.10.h. for clarity

 

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

Prior to updates, the policies were approved for use by Medicare Quality Committee.

For questions or additional information, please contact Wellcare By Allwell Provider Services at HMO: 1-800-977-7522 DSNP: 1-877-935-8023.