Medical policies A-Z

Additional medical policy information

Changes to medical policies

Medical technology is constantly evolving, and these medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time, and some may be withdrawn from use.

Wellmark's medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc. They are developed to assist in administering plan benefits and are not offers of coverage or medical advice.

Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies are subject to change without notice.

Medical policies are based on proven merits and scientific evidence

Wellmark bases its medical policies on:

• Data from peer-reviewed scientific literature
• Criteria developed by specialty societies
• Guidelines adopted by other health care organizations

Wellmark evaluates medical technologies based on the following criteria:

• The technology must have final approval from the appropriate governmental regulatory bodies
• The scientific evidence must permit conclusions concerning the effect of technology on health outcomes
• The technology must improve the net health outcomes
• The technology must be as beneficial as any established alternatives
• The improvement must be obtainable outside the investigational settings

To request Wellmark's consideration of a new technology, i.e., biologic, drug, procedure, or device, or new use of an existing technology, please download the technology assessment form.

Providers may send scientific evidence for the Wellmark medical policy research and development team to take into consideration during the annual review process to policym@Wellmark.com.

Custom Utilization Management (UM) criteria sets

Custom Utilization Management (UM) criteria sets are used for certain acute inpatient level of care hospital admissions.

• Utilization Management Criteria-Surgical-Inpatient Level of Care
• Utilization Management Criteria-Pediatric Bronchiolitis Inpatient Level of Care