Effective February 1, 2025: Clinical Policies

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-thalassemia

(MC.CP.MP.108)

Wellcare By Allwell (Medicare)

Policy updates include:

• Minor rewording in Description with no clinical impact
• Background updated with no impact on criteria
• References reviewed and updated

Cosmetic and Reconstructive Procedures

(MC.CP.MP.31)

Wellcare By Allwell (Medicare)

New Policy Overview:

• Reconstructive surgery is performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, surgery, infection, tumors or disease.
• This policy outlines the medical necessity criteria for cosmetic and reconstructive procedures. This policy criteria is sourced from Medicare Benefit Policy Manuals, Local Coverage Determinations (LCDs), The Women's Health and Cancer Rights Act (WHCRA), as well as treatment guidelines from the American Society of Plastic Surgeons and FDA approved indications for facial dermal injections.

Lantidra

(MC.CP.MP.250)

Wellcare By Allwell (Medicare)

Policy updates include:

• References reviewed and updated
• Reviewed by external specialist

Omisirge

(MC.CP.MP.249)

Wellcare By Allwell (Medicare)

Policy updates include:

• Description updated with no impact on criteria
• Added “Medicare” to health plans in Policy/Criteria I
• Background updated with no impact on criteria
• References reviewed and updated
• Reviewed by external specialist

Sacroiliac Joint Interventions for Pain Management

(MC.CP.MP.166)

Wellcare By Allwell (Medicare)

New Policy Overview:

• Treatment for sacroiliac joint (SIJ) pain and dysfunction is usually conservative (non-surgical) and focuses on pain relief. In patients who have failed to respond to conservative therapy, an SIJ injection can be helpful for both diagnostic and therapeutic purposes. SIJ injections are placed into the synovial sac of the SIJ may provide immediate and significant pain relief
• This policy outlines the medical necessity criteria for sacroiliac joint interventions for pain management. This policy criteria is sourced from Local Coverage Determinations (LCDs) Sacroiliac Joint Injections and Procedures (L39383) as well as treatment guidelines from the North American Spine Society