Clinical & Payment Policies

Clinical Policies

Clinical policies are one set of guidelines used to assist in administering health plan benefits, either by prior authorization or payment rules. They include but are not limited to policies relating to evolving medical technologies and procedures, as well as pharmacy policies. Clinical policies help identify whether services are medically necessary based on information found in generally accepted standards of medical practice; peer-reviewed medical literature; government agency/program approval status; evidence-based guidelines and positions of leading national health professional organizations; views of physicians practicing in relevant clinical areas affected by the policy; and other available clinical information.

All policies found in the Ambetter from WellCare of New Jersey Clinical Policy Manual apply to Ambetter from WellCare of New Jersey members. Policies in the Ambetter from WellCare of New Jersey Clinical Policy Manual may have either a Ambetter from WellCare of New Jersey or a “Centene” heading. Ambetter from WellCare of New Jersey utilizes InterQual® criteria for those medical technologies, procedures or pharmaceutical treatments for which a Ambetter from WellCare of New Jersey clinical policy does not exist. InterQual is a nationally recognized evidence-based decision support tool. You may access the InterQual® SmartSheet(s)™ for Adult and Pediatric procedures, durable medical equipment and imaging procedures by logging into the secure provider portal or by calling Ambetter from WellCare of New Jersey. In addition, Ambetter from WellCare of New Jersey may from time to time delegate utilization management of specific services; in such circumstances, the delegated vendor’s guidelines may also be used to support medical necessity and other coverage determinations. Other non-clinical policies (e.g., payment policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Clinical Policy Manuals or InterQual®criteria is payable by Ambetter from WellCare of New Jersey.

If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.

Clinical Policy List
A-G	H-P	Q-Z
Acupuncture (PDF) Effective Date: 1/1/2022	H Pylori Testing (PDF) Effective Date: 1/1/2022	Radial Head Implant (PDF) Effective Date: 1/1/2022
ADHD Assessment and Treatment (PDF) Effective Date: 1/1/2022	Heart-Lung Transplant (PDF) Effective Date: 1/1/2022	Radiofrequency Ablation of Uterine Fibroids (PDF) Effective Date: 1/1/2022
Air Ambulance (PDF) Effective Date: 1/1/2022	Holter Monitors (PDF) Effective Date: 1/1/2022	Reduction Mammoplasty and Gynecomastia Surgery (PDF) Effective Date: 1/1/2022
Allergy Testing (PDF) Effective Date: 1/1/2022	Home Birth (PDF) Effective Date: 1/1/2022	Repair of Nasal Valve Compromise (PDF) Effective Date: 1/1/2022
Allogeneic Hematopoietic Cell Transplants for Sickle Cell Anemia and Beta-Thalassemia (PDF) Effective Date: 1/1/2022	Home phototherapy for neonatal hyperbilirubinemia (PDF) Effective Date: 1/1/2022	Sacroiliac Joint Fusion (PDF) Effective Date: 1/1/2022
Ambulatory Surgery Center Optimization (PDF) Effective Date: 1/1/2022	Homocysteine Testing (PDF) Effective Date: 1/1/2022	Sacroiliac Joint Interventions for Pain Management (PDF) Effective Date: 1/1/2022
Articular Cartilage Defect Repairs (PDF) Effective Date: 1/1/2022	Hospice Services (PDF) Effective Date: 1/1/2022	Scanning computerized Ophthalmic Diagnostic Imaging (SCODI) (PDF) Effective Date: 1/1/2022
Assisted Reproductive Technology (PDF) Effective Date: 1/1/2022	Hyperemesis gravidarum treatment (PDF) Effective Date: 1/1/2022	Sclerotherapy and Chemical Endovenous Ablation for Varicose Veins (PDF) Effective Date: 1/1/2022
Bariatric Surgery (PDF) Effective Date: 1/1/2022	Hyperhidrosis treatments (PDF) Effective Date: 1/1/2022	Selective Dorsal Rhizotomy (PDF) Effective Date: 1/1/2022
Biofeedback (PDF) Effective Date: 1/1/2022	Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea (PDF) Effective Date: 1/1/2022	Selective Nerve Root Blocks and Transforaminal Epidural Injections (PDF) Effective Date: 1/1/2022
Bone-anchored hearing aid (PDF) Effective Date: 1/1/2022	Implantable Intrathecal Pain Pump (PDF) Effective Date: 1/1/2022	Short Inpatient Hospital Stay (PDF) Effective Date: 1/1/2022
Bronchial Thermoplasty (PDF) Effective Date: 1/1/2022	Implantable Loop Recorder (PDF) Effective Date: 6/22/2022	Skilled Nursing Facility Leveling (PDF) Effective Date: 1/1/2022
Burn Surgery (PDF) Effective Date: 1/1/2022	Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF) Effective Date: 1/1/2022	Skin Substitutes for Chronic Wounds (PDF) Effective Date: 1/1/2022
Cardiac Biomarker Testing for Acute MI (PDF) Effective Date: 1/1/2022	Inhaled nitric oxide (PDF) Effective Date: 1/1/2022	Spinal Cord Stimulation (PDF) Effective Date: 1/1/2022
Caudal or Interlaminar Epidural Steroid Injections (PDF) Effective Date: 1/1/2022	Intensity-Modulated Radiotherapy (PDF) Effective Date: 1/1/2022	Stereotactic Body Radiation Therapy (PDF) Effective Date: 1/1/2022
Clinical Trials (PDF) Effective Date: 1/1/2022	Intestinal and Multivisceral Transplant (PDF) Effective Date: 1/1/2022	Tandem Transplant (PDF) Effective Date: 1/1/2022
Cochlear Implant Replacements (PDF) Effective Date: 1/1/2022	Intradiscal Steroid Injections for Pain Management (PDF) Effective Date: 1/1/2022	Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF) Effective Date: 1/1/2022
Cosmetic and Reconstructive Surgery (PDF) Effective Date: 1/1/2022	Laser Skin Treatment (PDF) Effective Date: 1/1/2022	Thyroid Testing in Pediatrics (PDF) Effective Date: 1/1/2022
Dental Anesthesia (PDF) Effective Date: 1/1/2022	Long Term Care Placement Criteria (PDF) Effective Date: 1/1/2022	Total Artificial Heart (PDF) Effective Date: 1/1/2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF) Effective Date: 1/1/2022	Low-Frequency Ultrasound Wound Therapy (PDF) Effective Date: 1/1/2022	Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF) Effective Date: 1/1/2022
Digital EEG Analysis (PDF) Effective Date: 1/1/2022	Lung Transplantation (PDF) Effective Date: 1/1/2022	Transcatheter Closure of Patent Foramen Ovale (PDF) Effective Date: 1/1/2022
Disc Decompression Procedures (PDF) Effective Date: 1/1/2022	Lysis of Epidural Lesions (PDF) Effective Date: 1/1/2022	Trigger Point Injections for Pain Management (PDF) Effective Date: 1/1/2022
Discography (PDF) Effective Date: 1/1/2022	Measure Serum 1,25 Vitamin D (PDF) Effective Date: 1/1/2022	Ultrasound in Pregnancy (PDF) Effective Date: 1/1/2022
Donor lymphocyte infusion (PDF) Effective Date: 1/1/2022	Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF) Effective Date: 1/1/2022	Urinary Incontinence Devices and Treatments (PDF) Effective Date: 1/1/2022
Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF) Effective Date: 1/1/2022	Multiple Sleep Latency Testing (PDF) Effective Date: 1/1/2022	Urodynamic Testing (PDF) Effective Date: 1/1/2022
Durable Medical Equipment (DME) (PDF) Effective Date: 1/1/2022	Neonatal Abstinence Syndrome Guidelines (PDF) Effective Date: 1/1/2022	Vagus Nerve Stimulation (PDF) Effective Date: 1/1/2022
EEG in Evaluation of Headache (PDF) Effective Date: 1/1/2022	Neonatal Sepsis Management (PDF) Effective Date: 1/1/2022	Ventricular Assist Device (PDF) Effective Date: 1/1/2022
Electric Tumor Treating Fields (PDF) Effective Date: 1/1/2022	Nerve Blocks for Pain Management (PDF) Effective Date: 1/1/2022	Vitamin D Testing in Children (PDF) Effective Date: 1/1/2022
Endometrial Ablation (PDF) Effective Date: 1/1/2022	Neuromuscular Electrical Stimulation (NMES) (PDF) Effective Date: 1/1/2022	Wheelchair Seating (PDF) Effective Date: 1/1/2022
Essure Removal (PDF) Effective Date: 1/1/2022	NICU Apnea Bradycardia Guidelines (PDF) Effective Date: 1/1/2022	Wireless Motility Capsule (PDF) Effective Date: 1/1/2022
Evoked Potentials (PDF) Effective Date: 1/1/2022	NICU Discharge Guidelines (PDF) Effective Date: 1/1/2022
Experimental Technologies (PDF) Effective Date: 1/1/2022	Non-invasive Home Ventilators (PDF) Effective Date: 1/1/2022
External Ocular Photography (PDF) Effective Date: 1/1/2022	Non-myeloablative Allogeneic Stem Cell Transplants (PDF) Effective Date: 1/1/2022
Facet Joint Interventions (PDF) Effective Date: 1/1/2022	Obstetrical Home Health Care Programs (PDF) Effective Date: 1/1/2022
Fecal incontinence treatments (PDF) Effective Date: 1/1/2022	Optic Nerve Decompression Surgery (PDF) Effective Date: 1/1/2022
Ferriscan R2-MRI (PDF) Effective Date: 1/1/2022	Orthognathic Surgery (PDF) Effective Date: 1/1/2022
Fertility preservation (PDF) Effective Date: 1/1/2022	Osteogenic Stimulation (PDF) Effective Date: 1/1/2022
Fetal surgery in utero for prenatally diagnosed malformations (PDF) Effective Date: 1/1/2022	Outpatient Cardiac Rehabilitation (PDF) Effective Date: 1/1/2022
Fluorescein Angiography (PDF) Effective Date: 1/1/2022	Oxygen Use and Concentrators (PDF) Effective Date: 1/1/2022
Fundus Photography (PDF) Effective Date: 1/1/2022	Pancreas Transplant (PDF) Effective Date: 1/1/2022
Functional MRI (PDF) Effective Date: 1/1/2022	Panniculectomy (PDF) Effective Date: 1/1/2022
Gastric Electrical Stimulation (PDF) Effective Date: 1/1/2022	Pediatric Heart Transplant (PDF) Effective Date: 1/1/2022
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF) Effective Date: 1/1/2022	Pediatric Liver Transplant (PDF) Effective Date: 1/1/2022
Gender Affirming Procedures (PDF) Effective Date: 1/1/2022	Pediatric Oral Function Therapy (PDF) Effective Date: 1/1/2022
Gonioscopy (PDF) Effective Date: 1/1/2022	Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF) Effective Date: 1/1/2022
	Physical, Occupational, and Speech Therapy Services (PDF) Effective Date: 1/1/2022
	Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF) Effective Date: 1/1/2022
	Post Acute Care (PDF) Effective Date: 1/1/2022
	Posterior Tibial Nerve Stimulation for Voiding Dysfunction (PDF) Effective Date: 1/1/2022
	Proton and Neutron Beam Therapies (PDF) Effective Date: 1/1/2022

Clinical & Payment Policies

Clinical Policies

CLINICAL POLICIES