Medical Policies A-Z
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Medical policies serve as one set of guidelines for determining what medical services, procedures and devices may be eligible for coverage.
View the authorization table to determine when to request an authorization.
InterQual® criteria is used to evaluate whether a medical procedure or equipment is medically necessary.
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 Additional medical policies may be developed from time to time and some may be withdrawn from use.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.
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 PDF File.
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 Send Email.
Medical policies — alphabetical listing
To search for medical policies, use your computer's search function or view the alphabetical listing.
Wellmark's medical policies are displayed as PDFs. All policies include bookmarks to help you navigate to specific sections. You can view bookmarks by clicking the second icon in the left navigation menu.
Policies starting with A
- Abecma (Idecabtagene Vicleucel)* PDF File
- Ablative Procedures for the Peripheral Nerves to Treat Pain* PDF File
- Ablative Treatments for Occipital Neuralgia, Chronic Headaches and Atypical Facial Pain* PDF File
- Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses* PDF File
- Aduhelm PDF File
- Air Ambulance* PDF File
- Airway Clearance Devices in the Home Setting PDF File
- Allergy Immunotherapy PDF File
- Allergy Testing PDF File
- Ambulatory Cardiac Event Monitoring and Real-Time Outpatient Cardiac Telemetry PDF File
- Ambulatory Esophageal pH Monitoring PDF File
- Amniotic Membrane and Amniotic Fluid Grafts PDF File
- Amondys 45 PDF File
- Analysis of MGMT Promoter Methylation PDF File
- Anesthesia Services for Gastrointestinal Endoscopic Procedures PDF File
- Artificial Intervertebral Disc PDF File
- Autologous Chondrocyte Implant for Focal Articular Cartilage Lesions PDF File
- Automated Nerve Conduction Tests PDF File
Policies starting with B
- Bio-Engineered Skin and Soft Tissue Substitutes
- Biofeedback/Neurofeedback as a Treatment of Headache and other Disorders
- Bioimpedance Devices for Detection and Management of Lymphedema
- Biomarker Testing for Autoimmune Disease
- Bone Turnover Markers for Diagnosis and Management of Osteoporosis and Other Conditions
- Breyanzi (Lisocabtagene Maraleucel)
- Bronchial Thermoplasty
Policies starting with C
- Cardiac Contractility Modulation (CCM) Therapy PDF File
- Cardiac Hemodynamic Monitoring for the Management of Heart Failure in Outpatient Setting PDF File
- Cardiovascular Disease Risk Tests PDF File
- Carvykti (Ciltacabtagene Autoleucel)* PDF File
- Cellular Immunotherapy for Prostate Cancer - Provenge (Sipuleucel-T)* PDF File
- Chemical Peels PDF File
- Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsies) PDF File
- Cochlear Implant Replacement* PDF File
- Cognitive Rehabilitation PDF File
- Comprehensive Genomic Profiling for Selecting Targeted Therapies PDF File
- Computer-Assisted Corneal Topography PDF File
- Computer-Assisted Navigation for Orthopedic Surgery PDF File
- Confocal Laser Endomicroscopy PDF File
- Continuous Passive Motion (CPM) Devices in the Home Setting PDF File
- Corneal Cross-Linking PDF File
- Coronary Artery Calcium Scoring PDF File
- Cosmetic and Reconstructive Services PDF File
- Cryoablation, Radiofrequency Ablation, and Laser Ablation for Treatment of Chronic Rhinitis PDF File
Policies starting with D
- Decompression of the Intervertebral Disc Using Laser Energy (Laser Discectomy) or Radiofrequency-Coblation (Neuceloplasty) PDF File
- Deep Brain Stimulation (DBS) PDF File
- Dermatologic Applications of Photodynamic Therapy PDF File
- Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems PDF File
- Donor Lymphocyte Infusion (DLI) and Hematopoietic Progenitor Cell (HPC) Boost PDF File
- Dopamine Transporter Single-Photon Emission Computer Tomography PDF File
- Drug Testing in Pain Management and Substance Use Disorder Treatment PDF File
- Dry Needling PDF File
- Dynamic Posturography PDF File
E
- Echosclerotherapy, Mechanochemical Ablation and Endovenous Cryoablation, Photothermal Sclerosis and Cyanoacrylate Adhesive
- EGRIFTA™ (tesamorelin)
- Electronic Brachytherapy
- Enteral Therapy and Oral Formula
- Epidermal Growth Factor Receptor (EGFR) testing
- Eustachian Tube Dysfunction Treatment
- Evzio (naloxone auto-injector)
- Exhaled Nitric Oxide and Exhaled Breath Condensate
- Exondys 51 (eteplirsen)
- Expanded Genetic Panels to Assess Cancer Risk
- Expanded Genetic Panels to Identify Targeted Cancer Therapy
- Eyelid Thermal Pulsation for the Treatment of Dry Eye Syndrome (e.g. Lipiflow)
Policies starting with F
Policies starting with G
- Gastric Electrical Stimulation PDF File
- Gender Affirming Services PDF File
- Gene Expression Based Assays for Cancer of Unknown Primary PDF File
- Gene Expression Profiling and Protein Biomarkers for Prostate Cancer Management PDF File
- Gene Expression Profiling for Cutaneous Melanoma PDF File
- Gene Expression Profiling for the Management of Breast Cancer PDF File
- Gene Expression Profiling for Uveal Melanomas PDF File
- Genetic and Laboratory Testing for 5-fluorouracil (5-FU) Sensitivity PDF File
- Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer PDF File
- Genetic Testing for Acute Myeloid Leukemia PDF File
- Genetic Testing for BCR-ABL Fusion Gene PDF File
- Genetic Testing for Familial Cutaneous Malignant Melanoma PDF File
- Genetic Testing for Hereditary Cardiomyopathies and Arrhythmias PDF File
- Genetic Testing for Inherited Thrombophilia PDF File
- Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections and Related Disorders PDF File
- Genetic Testing for Predicting Recurrence of Colon Cancer PDF File
- Genetic Testing in Myeloproliferative Disease PDF File
Policies starting with H
- Heart/Lung Transplant* PDF File
- Hematopoietic Stem Cell Transplantation Autologous and Allogeneic* PDF File
- Hereditary Cancer Syndrome Multigene Panels Using Messenger RNA (mRNA) PDF File
- High Cost Naloxone Injectables PDF File
- High Dollar Drug Review PDF File
- High Intensity Focused Ultrasound (HIFU) PDF File
- Home Sleep Studies - Pediatric PDF File
- Homocysteine Testing PDF File
- Humanitarian Use Devices PDF File
- Hyperbaric Oxygen Therapy (HBOT) Systemic* and Topical Hyperbaric Oxygen Therapy (THOT) and Continuous Topical Oxygen Therapy (CTOT PDF File
Policies starting with I
- Image-Guided Minimally Invasive Decompression for Spinal Stenosis PDF File
- Implantable Bone Conduction Hearing Devices* PDF File
- Implantable Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea PDF File
- Implantable Peripheral Nerve Stimulation for the Treatment of Chronic Pain PDF File
- Implants for Metatarsal Joint Pain PDF File
- Injection Therapy for Headache Management PDF File
- Interim Policy on New FDA Approvals PDF File
- Interspinous and Interlaminar Stabilization/Distraction Devices PDF File
- Intracardiac Ischemia Monitoring PDF File
Policies starting with K
Policies starting with L
- Laboratory Testing for Transplant Rejection PDF File
- Laparoscopic, Percutaneous and Transcervical Techniques for Uterine Fibroid Myolysis PDF File
- Laser Interstitial Thermal Therapy (LITT) PDF File
- Laser Treatment for Nail Fungus PDF File
- Leadless Cardiac Pacemaker PDF File
- Leqembi PDF File
- Low-Level Laser Therapy and High-Power Laser Therapy PDF File
- Lung and Lobar Lung Transplant* PDF File
- Lutathera (Lutetium Lu 177 Dotatate)* PDF File
Policies starting with M
- Management of Dry Eye Syndrome PDF File
- Manipulation under Anesthesia PDF File
- Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis using Ultrasound PDF File
- Measurement of Serum Antibodies to Selected Biologic Agents PDF File
- Mechanical Stretching Devices PDF File
- Medical Foods and Specialized Formula for the Treatment of Inborn Errors of Metabolism PDF File
- Miscellaneous Bariatric Procedures PDF File
- Miscellaneous Surgical Treatments of Back Pain PDF File
- Miscellaneous Treatments for Varicose Veins/Venous Insufficiency PDF File
- Molecular Analysis (Including Liquid Biopsy) for Targeted Therapy or Immunotherapy of Non-Small Cell Lung Cancer PDF File
- Molecular Markers in Fine Needle Aspirates of the Thyroid PDF File
- Molecular Testing in the Management of Pulmonary Nodules PDF File
- MRI-Guided High-Intensity Focused Ultrasound (MRgFUS) Ablation PDF File
- Multimarker Serum Testing Related to Ovarian Cancer PDF File
Policies starting with N
- Neurofeedback PDF File
- Next Generation Sequencing for the Assessment of Measurable Residual Disease (MRD) PDF File
- Noncontact Ultrasound Treatment for Wounds PDF File
- Non-invasive Fetal RhD Genotyping Using Cell-Free Fetal DNA PDF File
- Non-invasive Glucose Monitoring Devices PDF File
- Non-invasive Heart Failure and Arrhythmia Management and Monitoring System PDF File
- Non-Powered Negative Pressure Wound Therapy PDF File
Policies starting with O
- Occipital Nerve Stimulation PDF File
- Off-label Drug Use PDF File
- Optical Coherence Tomography of the Anterior Eye Segment PDF File
- Orthognathic Surgery* PDF File
- Osteochondral Allografts and Autografts in the Treatment of Focal Articular Cartilage Lesions PDF File
- Ovarian and Internal Iliac Vein Endovascular Occlusion as a Treatment of Pelvic Congestion Syndrome PDF File
Policies starting with P
- Pancreas Transplants* (Including Simultaneous Pancreas-Kidney, Pancreas alone, and Pancreas after Kidney) PDF File
- Pancreatic Islet Cell Transplant PDF File
- Percutaneous Intracranial Angioplasty and Stenting PDF File
- Percutaneous Left-Atrial Appendage Closure Devices for Stroke and Prevention in Atrial Fibrillation PDF File
- Percutaneous Ultrasonic Ablation of Soft Tissue PDF File
- Peripheral Subcutaneous Field Stimulation (PSFS) PDF File
- Peroral Endoscopic Myotomy (POEM) Procedures PDF File
- Pharmacogenomic and Pharmacogenetic Testing for Drug Metabolism Status - Non-Cancer Indications PDF File
- Platelet - Rich Plasma and Autologous Protein Solution for Orthopedic Applications PDF File
- Platelet - Rich Plasma for Wound Healing and the Treatment of Other Non-Orthopedic Indications PDF File
- Pluvicto PDF File
- Pneumatic Compression Devices in the Home Setting PDF File
- Positron Emission Tomography (PET) for Surveillance of Oncologic Indications* PDF File
- Prenatal Screening; Cell-Free Fetal DNA Testing PDF File
- Prolotherapy PDF File
- Prostate-Specific Antigen Screening for Prostate Cancer PDF File
- Proteomic Testing for Systemic Therapy in Non-Small Cell Lung Cancer PDF File
- Proton Beam Radiation Therapy* PDF File
- Pulsed Radiofrequency Ablation PDF File
Policies starting with Q
Policies starting with R
Policies starting with S
- Sacral Nerve Stimulation/Neuromodulation PDF File
- Saliva Hormone Tests PDF File
- Scintimammography/Breast Specific Gamma Imaging (BSGI)/Molecular Breast Imaging (MBI)/Positron Emission Mammography (PEM) PDF File
- Screening for Lung Cancer Using Low Dose Computed Tomography (LDCT) PDF File
- Screening for Vertebral Fracture Assessment with Dual X-Ray Absorptiometry (DXA) PDF File
- Sensory Integration Therapy and Auditory Integration Therapy PDF File
- Serum Tumor Markers in the Management of Malignancies PDF File
- Small Bowel Transplant* PDF File
- Small Bowel/Liver and Multivisceral Transplant* PDF File
- Spinal Cord and Dorsal Root Ganglion Stimulation PDF File
- Stem Cell Therapy for Lung Disease* PDF File
- Stem Cell Therapy for Orthopedic Indications (Including Allograft Bone Products Used with Stem Cells) PDF File*
- Stem Cell Therapy for Peripheral Arterial Disease PDF File
- Stereotactic Surgery and Stereotactic Radiosurgery PDF File
- Steroid – Eluting Sinus Stents and Implants PDF File
- Subtalar Arthroereisis PDF File
- Surface Electromyography (sEMG) PDF File
- Surgical Treatment of Lymphedema PDF File
- Surgical Treatment of Sacroiliac Joint Pain PDF File
Policies starting with T
- Tecartus (Brexucabtagene Autoleucel)* PDF File
- Temporomandibular Joint (TMJ) Dysfunction: Diagnosis and Treatments PDF File
- Testing in the Diagnosis and Management of Inflammatory Bowel Disease (IBD) PDF File
- Therapeutic Plasmapheresis or Plasma Exchange PDF File
- Thermography and Temperature Gradient Studies PDF File
- Topographic Genotyping PDF File
- Transcranial Magnetic Stimulation* PDF File
- Treatments for Benign Prostatic Hyperplasia (BPH) PDF File
- Treatment for Gastroesophageal Reflux Disease (GERD) PDF File
- Treatment of Congenital Athymia (Rethymic) PDF File
- Treatment of Nasal Valve Collapse PDF File
- Treatment of Speech and Language Disorders* PDF File
- Tumor Treatment Fields Therapy* PDF File
Policies starting with U
Policies starting with V
- Vagus Nerve Stimulation (VNS) PDF File
- Vascular Endothelial Growth Factor (VEGF) Inhibitors for Ophthalmic Use PDF File
- Vertebral Augmentation PDF File
- Vertebral Axial Decompression PDF File
- Vertebral Body Stapling and Vertebral Body Tethering for Treatment of Progressive Scoliosis PDF File
- Viltepso (viltolarsen) PDF File
- Vision Therapy/Orthoptic Training PDF File
- Vitamin D Testing PDF File
- Vivitrol (naltrexone for extended-release injectable suspension) PDF File
- Vyondys 53 PDF File