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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 Additional medical policies may be developed from time to time and some may be withdrawn from use.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 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 Q