POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
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CPG Grid
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Added the following Physical Health guidelines: Combined Coronary Artery Disease section and Congenital Disorders to Cardiovascular Disease, Added ISTH- clinical practice guideline for treatment of congenital hemophilia A and B based on the Grading of Recommendations Assessment, Development, and Evaluation methodology
- Updated Hyperlipidemia section to Dyslipidemia and added VA/DoD Clinical Practice Guidelines Management of Dyslipidemia for Cardiovascular Risk Reduction (2020); AAFP- Blood Pressure Targets in Adults With Hypertension: A Clinical Practice Guideline From the AAFP (2022), VA/DoD- Clinical Practice Guidelines Diagnosis and Management of Hypertension (HTN) in Primary Care (2020); ACOG Clinical Practice Guideline No. 2. Management of Postmenopausal Osteoporosis (April 2022); Women’s Preventive Services Initiative (WPSI), American College of Obstetricians and Gynecologists (ACOG)- Recommendations for Well-Woman Care; WHO clinical treatment guideline for tobacco cessation in adults; NCCN Clinical Practice Guidelines in Oncology, Smoking Cessation, Version 3.2022; Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline; American Association of Clinical Endocrinologists (AACE), The Obesity Society, American Society of Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists- Clinical Practice Guidelines For The Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update; IFSO-WGO GUIDELINES ON OBESITY (2023)
- Updated the following Physical Health guidelines with new publication revision dates: 2024 GINA Report, Global Strategy for Asthma Management and Prevention; Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2025 Report); IDSA Guidelines of the Treatment and Management of Patients with COVID-19 (Updated August 2024); USPSTF- Prevention of Human Immunodeficiency Virus (HIV) Infection: Preexposure Prophylaxis (2023); ACOG- Routine Human Immunodeficiency Virus Screening (2014- reaffirmed 2024); CDC- Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the ACIP United States, 2024-2025 Influenza Season; CDC- Adult Immunization Schedule. Recommendations for Ages 19 years or older, United States, 2025; CDC- Child and Adolescent Immunization Schedule. Recommendations for Ages 18 years or younger, United States, 2025; Bright Futures/American Academy of Pediatrics- Periodicity Schedule: Recommendations for Preventive Pediatric Health Care (2024); Final Recommendation Statement High Body Mass Index in Children and Adolescents: Interventions; CDC- Clinical Testing and Diagnosis for Zika Virus Disease For Healthcare Providers: New Zika and Dengue Testing Guidance (May 15, 2024)
- Removed the following guidelines: HHS, NIH and NHLBI Asthma Care Quick Reference: Diagnosing and Managing Asthma. Guidelines from the National Asthma Education and Prevention Program. Expert Panel Report 3. (Revised 2012); Journal of Orthopaedic and Sports Physical Therapy- Low Back Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health (2012); NIH- Coronavirus Disease 2019 Treatment Guidelines; NICE Managing Medicines for Adults Receiving Social Care in the Community (2017); General Evidence Based Medicine- Choosing Wisely; HHS/HRSA- Guide for HIV/AIDS Program Clinical Care (2014); 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults; U.S. Department of Health and Human Services, NIH, NHLBI - Managing Overweight and Obesity in Adults: Systematic Evidence Review from the Obesity Expert Panel (2013)
- Added the following Behavioral Health guidelines: AAFP Generalized Anxiety disorder and Panic disorder in adults; Added Borderline Personality Disorder section and included APA Practice Guideline for the Treatment of Patients with Borderline Personality Disorder, 2nd edition; ASAM Clinical Practice Guideline on the Management of Stimulant Use Disorder; ASAM Clinical Practice Guideline on Alcohol Withdrawal Management; ACOG Committee Opinion Health Care for Transgender and Gender Diverse Individuals Number 823 (March 2021, reaffirmed 2024)
- Updated the following Behavioral Health guidelines with new publication revision dates: CASP Applied Behavior Analysis Practice Guidelines for the Treatment of Autism Spectrum Disorder Third Edition (April 2024); Federal Guidelines for Opioid Treatment Programs (2024); VA Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide (2024)
- Removed the following guidelines: ADAA Clinical Practice Review for Generalized Anxiety Disorder; AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder (February 2014); NICE Generalized Anxiety Disorder and Panic Disorder in Adults: Management (Updated June 2020), NICE- Eating disorders: recognition and treatments (2017, updated December 2020) AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Posttraumatic Stress Disorder (April 2010); AACAP Practice Parameter for the Assessment and Treatment of Children and Adolescents with Schizophrenia (2013)
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Donor Lymphocyte Infusion
(MC.CP.MP.101)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Added clarifying language to Criteria II
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Implantable Wireless Pulmonary Artery Pressure Monitoring
(MC.CP.MP.160)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Added the following medically necessary indications to criteria I:
- Member is enrolled in the CMS-approved coverage with evidence development (CED) study
- Diagnosis of chronic HF of at least three months duration and in New York Heart Association (NYHA) functional Class II or III within the past 30 days, prior to PAPS implantation, regardless of left ventricular ejection fraction (LVEF)
- History of HF hospitalization or urgent HF visit (emergency room or other outpatient visit requiring intravenous diuretic therapy) within the past 12 months, or elevated natriuretic peptides within the past 30 days
- On maximally tolerated guideline-directed medical therapy (GDMT) for at least three months prior to PAPS implantation
- Evaluated for, and received if appropriate, an implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy (CRT)-Pacemaker (CRT-P), or CRT-Defibrillator (CRT-D). Implantation of the device must occur at least three months prior to PAPS implantation
- No major cardiovascular event (e.g., unstable angina, myocardial infarction, percutaneous coronary intervention, open heart surgery, or stroke) within the last three months prior to PAPS implantation
- Possessing adequate technology to ensure reliable remote connectivity to the IPAPS device
- Must not have PAPS implantation occur during a hospital admission for an acute HF episode
- Description and Background updated with no impact on criteria
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Lung Transplantation
(MC.CP.MP.57)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Annual review
- Updated glomerular filtration rate from < 30 to < 40 mL/min/1.73m2 in Criteria I.C.2
- Updated Criteria I.C.9.a. to include at least three months prior to transplantation
- Removed additional information regarding heart transplant waiting list in Criteria I.C.9.b
- Added Criteria I.C.9.d. regarding chronic wasting or severe malnutrition
- Expanded Criteria I.C.13. regarding active substance use or dependence and added Criteria I.C.14. regarding documentation of abstinence from substance use
- Added Criteria I.D.2.h., Criteria I.D.2.i, and Criteria I.D.2.j. regarding alveolar capillary dysplasia, pulmonary vein stenosis refractory to intervention, and pulmonary veno-occlusive disease
- Background updated with no impact to criteria
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Modulated Radiation Therapy (IMRT)
(MC.CP.MP.69)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Edits to description and background with no impact on criteria
- Removed I.A., B., and C., along with II.A. – E
- Added I.A. - D, along with I.E.1. – 8
- Added note "The above indications……all-inclusive listing"
- Updated CPT codes
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Pediatric Kidney Transplant
(MC.CP.MP.246)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Background updated with no clinical significance
- References reviewed and updated
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Peripheral Nerve Blocks and Ablation of Peripheral Nerves for Pain Management
(MC.CP.MP.170)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Title of policy updated to include ablation of peripheral nerves for pain management
- Description updated to include peripheral nerve ablations and minor grammatical updates
- Updated Criteria I. from diagnostic and therapeutic purposes to diagnostic and/or therapeutic purposes
- Added note to Criteria I.A. for clarity
- Added Criteria IV. regarding the use of peripheral/ganglion nerve blocks or neurolysis for any condition not indicated elsewhere in this policy
- Added Criteria V. regarding peripheral nerve destruction using cryoablation or laser, chemical, electrical, or radiofrequency ablation
- Added CPT code 64640
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