WellCare Coverage Criteria
Latest WellCare coverage criteria updates25
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-07-01Payment Policy: Sepsis DiagnosisThis policy governs coding validation and reimbursement review processes for inpatient facility claims with a sepsis diagnosis for WellCare members across all product types (adult inpatient encounters). It describes documentation requirements, clinical criteria used to validate sepsis, and pre- and post-pay audit practices.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Clinical Policy: Hospice ServicesDefines medical necessity criteria, required documentation, severity-of-illness criteria, levels of hospice care, and not-medically-necessary conditions for hospice benefits for members/enrollees under the plan.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-01Concert Genetics Genetic Testing: Aortopathies and Connective Tissue Disorders V1.2024This policy governs medical necessity criteria and coding for genetic testing (single-gene, targeted familial variant, and multigene panels) used to diagnose or confirm hereditary aortopathies and connective tissue disorders for WellCare members.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-03-01CONCERT GENETIC TESTING: HEMATOLOGIC CONDITIONS (NONCANCEROUS)Defines medical necessity and investigational indications for genetic and variant testing used to diagnose inherited, non-malignant hematologic disorders (e.g., thrombophilia, hemoglobinopathies, hemophilia, G6PD, von Willebrand). Applies to providers ordering genetic testing for covered members.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyAcupuncture coverageDefines medical necessity criteria, limitations, and coding guidance for needle acupuncture when it is a covered benefit under the health plan; applies to providers submitting claims for members covered by WellCare plans that adopt this policy.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyAllogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and β‑ThalassemiaMedical necessity criteria and coverage stance for allogeneic hematopoietic cell transplantation (HCT) to treat sickle cell anemia and homozygous β‑thalassemia for members of WellCare-affiliated health plans; intended for providers requesting transplant authorization and utilization review.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyApplication of the Concert Genetics Laboratory Testing Clinical Policies for Medicare BeneficiariesDefines how Centene-affiliated Medicare Advantage plans apply Medicare NCDs/LCDs and, where those do not fully establish coverage for a laboratory test, how Concert Genetics clinical policies are used to determine medical necessity for laboratory testing. Affects providers ordering lab tests for Medicare Advantage members of Centene-affiliated plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyCONCERT INFECTIOUS DISEASE: VECTOR-BORNE AND TROPICAL DISEASES TESTINGOutpatient clinical coverage criteria for laboratory testing (serologic and nucleic acid/PCR) for Lyme disease (Borrelia burgdorferi) and Zika virus, specifying medically necessary indications and tests considered not supported by current evidence.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Articular Cartilage Defect RepairsMedical necessity criteria and coding guidance for autologous chondrocyte implantation, osteochondral allograft/autograft transplantation, and meniscal allograft transplant of the knee for members/enrollees of WellCare (Centene-affiliated) health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Durable Medical Equipment and Orthotics and Prosthetics GuidelinesGoverns medical necessity criteria, coding, and coverage rules for durable medical equipment (DME), orthotics, and prosthetics for WellCare members; applies to providers requesting coverage for these items. Partial policy content provided (sectioned equipment-specific criteria and HCPCS mappings).All WellCare updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Heart-Lung TransplantDefines medical necessity criteria, contraindications, and coding implications for heart-lung transplantation for members/enrollees of WellCare (Centene-affiliated) health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Osteogenic StimulationMedical necessity criteria for electrical (invasive and noninvasive) and ultrasonic (LIPUS) osteogenic stimulators to enhance bone healing; governs coverage decisions for WellCare/Centene-affiliated health plans and affects providers requesting these devices.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyClinical Policy: Polymerase Chain Reaction Respiratory Viral Panel TestingMedical necessity criteria and coding guidance for multiplex respiratory PCR (RVP) testing across inpatient and outpatient settings for WellCare members; applies to providers ordering and billing these tests.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyCoding Implications — Syndromic Multiplex GI Pathogen Panels and H. pylori Testing (Outpatient)Defines medical necessity criteria and coding for outpatient syndromic multiplex GI pathogen panels and Helicobacter pylori noninvasive tests; affects ordering providers, laboratories, and claims reviewers for WellCare members.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyCoverage Criteria: HPV genotyping, Hepatitis C testing, and Group B Streptococcus screeningOutpatient medical necessity criteria for HPV genotyping (high- and low-risk), hepatitis C antibody and nucleic acid/PCR testing, and group B streptococcus (GBS) vaginal-rectal screening; applies to members/enrollees of the health plan.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyDonor Lymphocyte Infusion (DLI)Medical necessity criteria and coding implications for donor lymphocyte infusion (DLI) after allogeneic hematopoietic stem cell transplantation (HSCT) for Medicare-affiliated Centene Corporation health plans; describes indications, limitations, and referenced evidence.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyExtended ophthalmoscopyMedical necessity criteria and coding guidance for extended ophthalmoscopy examinations of the posterior eye, governing coverage decisions for providers and claims reviewers for WellCare (Centene/Envolve) health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyFacility-based Sleep Studies for Obstructive Sleep ApneaThis policy provides medical necessity guidance and coverage criteria for facility-based sleep studies (polysomnography) used in the diagnosis and management of obstructive sleep apnea for members of the Health Plan.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyFacility-based Sleep Studies for Obstructive Sleep ApneaMedical necessity criteria and coding guidance for facility-based polysomnography (PSG), split-night studies, and CPAP/BiPAP titration for adults with suspected obstructive sleep apnea; applies to WellCare/Centene-affiliated health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyFerriScan R2-MRIDefines medical necessity criteria for use of the FerriScan R2-MRI test to quantify liver iron concentration (LIC) in members suspected of iron overload; applies to providers submitting coverage requests to WellCare health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyFetal Surgery in Utero for Prenatally Diagnosed MalformationsDefines medical necessity criteria and coding references for performing in-utero fetal surgery for specific prenatally diagnosed fetal malformations for members of WellCare/Centene-affiliated health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyGenetic Testing: Epilepsy, Neurodegenerative, and Neuromuscular Disorders — Coverage CriteriaCriteria and coding guidance for genetic testing used to diagnose hereditary epilepsy, neurodegenerative, and neuromuscular diseases when conventional diagnostics are inconclusive; intended for providers ordering or billing these tests under WellCare.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyGenetic Testing: Gastroenterologic Disorders (Non‑Cancerous) — Coverage CriteriaDefines medical necessity and investigational indications for genetic and genomic testing used to diagnose or rule out common non-cancerous gastrointestinal disorders for WellCare members and affiliated Centene health plans.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyGenetic Testing: Lung Disorders (SERPINA1 / AATD and other genetic lung disorders)Defines medical necessity criteria for genetic testing of alpha-1 antitrypsin deficiency (SERPINA1) and guidance for testing other rare genetically-associated lung disorders; applies to providers requesting genetic tests for WellCare members.All WellCare updates
- Coverage CriteriaClinical/Medical PolicyGenetic Testing: Metabolic, Endocrine, and Mitochondrial DisordersDefines medical necessity criteria and coding guidance for genetic and molecular testing for hereditary metabolic, endocrine, and mitochondrial disorders for WellCare members.All WellCare updates
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Tool Description
Search WellCare coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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