POLICY
| APPLICABLE PRODUCTS
| NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
|
Donor Lymphocyte Infusion
(MC.CP.MP.101)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Minor rewording in Description and Background updated with no impact on criteria
|
Implantable Wireless Pulmonary Artery Pressure Monitoring
(MC.CP.MP.160)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Description updated with no impact to criteria
|
Intensity-Modulated Radiotherapy
(MC.CP.MP.69)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Added criteria I.B.8, Hodgkin’s and non-Hodgkin’s lymphoma in close proximity to critical structures
- Added criteria I.B.9, Select rectal cancer cases where there is lymph node involvement or require treatment of the inguinal lymph nodes
- Added criteria I.B.10, Soft tissue sarcoma when organ at risk dose constraints cannot be met
|
Lantidra (donislecel) Allogeneic Pancreatic Islet Cellular Therapy
(MC.CP.MP.250)
| Wellcare By Allwell (Medicare)
| New Policy Overview:
- Policy Description: This policy describes the medical necessity criteria for Lantidra (donislecel), an allogeneic pancreatic islet cellular therapy, used for the treatment of type 1 diabetes in those who are unable to reach target hemoglobin A1c (HbA1c)
- Includes policy criteria, background, and coding implications
|
Lung Transplantation
(MC.CP.MP.57)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Updated I.C.2. from GFR < 40 mL/min/1.73m2 to GFR < 30 mL/min/1.73m2
- Expanded I.C.9. with qualifying criteria for members who are HIV positive
- Updated I.D.2.a.1. from FEV1<25% to FEV1<30%
|
Pediatric Kidney Transplant
(MC.CP.MP.246)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Updated contraindication I.B.2., adding a.-c: a. CD4 cell count > 200 cells/mm3; b. Absence of active AIDS-defining opportunistic infection; c. Member/enrollee is currently on effective ART (antiretroviral therapy)
|
Peripheral Nerve Blocks
(MC.CP.MP.170)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Added the following note under section I. “If administered as part of a surgery or other procedure, coding for peripheral/ganglion nerve blocks should follow proper coding practices and would not be subject to prior authorization or payment separately from the procedure”
- Added “and neurolysis” to III.B
|
Short Inpatient Hospital Stay
(MC.CP.MP.182)
| Wellcare By Allwell (Medicare)
| Policy updates include:
- Updated criteria I.A. by removing 2023 inpatient only link
- Updated description and background with no clinical significance
|
Skin and Soft Tissue Substitutes for Chronic Wounds
(MC.CP.MP.185)
| Wellcare By Allwell (Medicare)
| New Policy Overview:
- Policy Description: This policy outlines the medical necessity criteria for skin substitutes for diabetic foot ulcers (DFU) and Venous Leg Ulcers (VLU) in the treatment of chronic wounds. This policy criteria is sourced from Local Coverage Determinations (LCDs) Wound Application of Cellular and/or Tissue Based Products (CTPs), Lower Extremities (L36690), Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities (L36377), and Application of Bioengineered Skin Substitutes to Lower Extremity Chronic Non-Healing Wounds (L35041) and a clinical practice guideline from the American Society of Vascular Surgery on the Diabetic Foot
- Includes skin and wound criteria, indicators or scenarios for chronic wound substitutes, background, and coding implications
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