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Effective August 20, 2026: Clinical Policies

Date: 05/21/26

Wellcare By Allwell and Wellcare By Superior HealthPlan (Duals) 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 August 20, 2026, at 12:00AM.

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:

  • Description updated to include study information for the treatment of severe aplastic anemia with Omisirge
  • Updated Criteria I. to include severe aplastic anemia as a medically necessary indication for Omisirge

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:

  • Policy description updated to note that the applicable NCDs, the Medicare Benefit Policy Manual, and the Medicare Claims Processing Manual do not provide sufficient coverage criteria to consistently determine medical necessity and noted why the applicable criteria offered by CMS and Medicare benefit policy and claims processing manuals were supplemented with this policy

Donor Lymphocyte Infusion

(MC.CP.MP.101)

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

Policy Updates Include:

  • Annual review
  • Coding and descriptions reviewed
  • References reviewed and updated

Home Ventilators

(MC.CP.MP.184)

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

Policy Updates Include:

  • Annual review
  • Added note under Description to state that COPD is out of scope for this policy
  • Reformatted entire criteria I. to support removal of previous criteria I.B. regarding chronic respiratory failure due to COPD
  • Removed example of chronic respiratory failure following COPD from Criteria IV

Intensity-Modulated Radiotherapy

(MC.CP.MP.69)

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

Policy Updates Include:

  • I.E.6.c. changed from “endometrial cancer” to “extremity sarcoma”

Lung Transplantation

(MC.CP.MP.57)

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

Policy Updates Include:

  • Annual review
  • Reviewed codes and descriptions

Pediatric Kidney Transplant

(MC.CP.MP.246)

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

Policy Updates Include:

  • Updated contraindications I.B.4 and I.B.5 to be in line with each specific body system
  • Removed contraindication I.B.9 for acute pancreatitis contraindication

Skin and Soft Tissue Substitues

(MC.CP.MP.185)

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

Policy Updates Include:

  • Changed policy name to “Skin and Soft Tissue Substitutes”
  • Description section updated to include criteria sources for new indications
  • In Notes section, added additional bullet points to refer to CP.MP.186 and MC.CP.MP.31, as applicable
  • In I.H.1.d.vi., I.H.2.d.iii., II.B.1.f. and II.B.2.c., deleted code Q4106 was replaced with code Q4431
  • In Note in I.H. and II.D., removed “16”
  • Added criteria IV. regarding skin substitute use for burn treatment, with IV.B. through IV.D. and IV.F. moved from CP.MP.186
  • Added criteria V. regarding skin substitute use for breast reconstruction
  • Added criteria VI. regarding skin substitute use for dystrophic epidermolysis bullosa
  • Added criteria VII. regarding skin substitute use for post-reconstructive surgery of abdominal wall wounds
  • Added criteria VIII. regarding indications considered not medically necessary
  • Added criteria IX. regarding indications not supported by current evidence
  • Throughout criteria section, replaced all skin substitute verbiage to “skin and soft tissue substitute/CTP”
  • Background section updated and includes new sections on burns, breast reconstruction, dystrophic epidermolysis, and post-reconstruction surgery of abdominal wall wounds
  • Updated titles of coding tables
  • Coding reviewed and updated
  • Added HCPCS Code Table 1
  • To HCPCS Code Table 1, added codes G0681, G0682, G0683, and G0684
  • Added Note under HCPCS Code Table 2
  • Combined previous Table 2 and Table 3 into HCPCS Code Table 2
  • To HCPCS Code Table 2, added the following: A2012, A2043, A2044, A4100, C1781, C9363, C9399, Q4104, Q4108, Q4116, Q4130, Q4182, Q4431, and Q4433
  • From HCPCS Code Table 2, removed Q4106
  • To HCPCS Code Table 3, added the following codes: A2026, A2028 to A2039, A2040, A2041, A2042, A2045, C8002, C9250, Q4135, Q4175, Q4310 to Q4373, Q4375 to Q4380, Q4382 to Q4417, Q4418, Q4419, Q4420, Q4421, Q4422, Q4423, Q4424, Q4425, Q4426, Q4427, Q4428, Q4429, Q4435, Q4436, Q4437, Q4438, Q4439, and Q4440
  • To HCPCS Code Table 3, removed the following codes: A2012, C9363, Q4104, Q4108, Q4116, Q4130, Q4182, Q4210, Q4231, and Q4244

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 Provider Services at: