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 EEG (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
Ambulatory Surgery Center Optimization (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
Antithrombin III (Thrombate III, Atryn) (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
Articular Cartilage Defect Repairs (PDF)
Effective Date: 1/1/2022		 Hyperhidrosis treatments (PDF)
Effective Date: 1/1/2022		 Selective Dorsal Rhizotomy (PDF)
Effective Date: 1/1/2022
Assisted Reproductive Technology (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
Bariatric Surgery (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
Biofeedback (PDF)
Effective Date: 1/1/2022		 Implantable Wireless Pulmonary Artery Pressure Monitoring (PDF)
Effective Date: 1/1/2022		 Skilled Nursing Facility Leveling (PDF)
Effective Date: 1/1/2022
Bone-anchored hearing aid (PDF)
Effective Date: 1/1/2022		 Inhaled nitric oxide (PDF)
Effective Date: 1/1/2022		 Skin Substitutes for Chronic Wounds (PDF)
Effective Date: 1/1/2022
Bronchial Thermoplasty (PDF)
Effective Date: 1/1/2022		 Intensity-Modulated Radiotherapy (PDF)
Effective Date: 1/1/2022		 Spinal Cord Stimulation (PDF)
Effective Date: 1/1/2022
Burn Surgery (PDF)
Effective Date: 1/1/2022		 Intestinal and Multivisceral Transplant (PDF)
Effective Date: 1/1/2022		 Stereotactic Body Radiation Therapy (PDF)
Effective Date: 1/1/2022
Cardiac Biomarker Testing for Acute MI (PDF)
Effective Date: 1/1/2022		 Intradiscal Steroid Injections for Pain Management (PDF)
Effective Date: 1/1/2022		 Tandem Transplant (PDF)
Effective Date: 1/1/2022
Caudal or Interlaminar Epidural Steroid Injections (PDF)
Effective Date: 1/1/2022		 Laser Skin Treatment (PDF)
Effective Date: 1/1/2022		 Testing for Select Genitourinary Conditions (previously Diagnosis of Vaginitis) (PDF)
Effective Date: 1/1/2022
Cell-free Fetal DNA Testing (PDF)
Effective Date: 1/1/2022		 Long Term Care Placement Criteria (PDF)
Effective Date: 1/1/2022
 Thymus Transplantation (PDF)
Effective Date: 1/1/2022
Clinical Trials (PDF)
Effective Date: 1/1/2022		 Low-Frequency Ultrasound Wound Therapy (PDF)
Effective Date: 1/1/2022		 Thyroid Testing in Pediatrics (PDF)
Effective Date: 1/1/2022
Cochlear Implant Replacements (PDF)
Effective Date: 1/1/2022		 Lung Transplantation (PDF)
Effective Date: 1/1/2022
 Total artificial heart (PDF)
Effective Date: 1/1/2022
Cosmetic and Reconstructive Surgery (PDF)
Effective Date: 1/1/2022		 Lysis of Epidural Lesions (PDF)
Effective Date: 1/1/2022
 Total Parenteral Nutrition and Intradialytic Parenteral Nutrition (PDF)
Effective Date: 1/1/2022
Dental Anesthesia (PDF)
Effective Date: 1/1/2022		 Measure Serum 1,25 Vitamin D (PDF)
Effective Date: 1/1/2022		 Transcatheter closure of patent foramen ovale (PDF)
Effective Date: 1/1/2022
Diaphragmatic/Phrenic Nerve Stimulation (PDF)
Effective Date: 1/1/2022		 Mechanical Stretching Devices for Joint Stiffness and Contracture (PDF)
Effective Date: 1/1/2022
 Trigger Point Injections for Pain Management (PDF)
Effective Date: 1/1/2022
Digital EEG Analysis (PDF)
Effective Date: 1/1/2022
 Multiple Sleep Latency Testing (PDF)
Effective Date: 1/1/2022
 Ultrasound in Pregnancy (PDF)
Effective Date: 1/1/2022
Disc Decompression Procedures (PDF)
Effective Date: 1/1/2022		 Neonatal abstinence syndrome guidelines (PDF)
Effective Date: 1/1/2022
 Urinary Incontinence Devices and Treatments (PDF)
Effective Date: 1/1/2022
Discography (PDF)
Effective Date: 1/1/2022		 Neonatal sepsis management (PDF)
Effective Date: 1/1/2022
 Urodynamic Testing (PDF)
Effective Date: 1/1/2022
Donor lymphocyte infusion (PDF)
Effective Date: 1/1/2022		 Nerve Blocks for Pain Management (PDF)
Effective Date: 1/1/2022
 Vagus Nerve Stimulation (PDF)
Effective Date: 1/1/2022
Drugs of Abuse: Definitive Testing (previously Outpatient Testing for Drugs of Abuse) (PDF)
Effective Date: 1/1/2022		 Neuromuscular Electrical Stimulation (NMES) (PDF)
Effective Date: 1/1/2022
 Ventricular Assist Device (PDF)
Effective Date: 1/1/2022
Durable Medical Equipment (DME) (PDF)
Effective Date: 1/1/2022		 NICU Apnea Bradycardia Guidelines (PDF)
Effective Date: 1/1/2022
 Video Electroencephalographic Monitoring (PDF)
Effective Date: 1/1/2022
EEG in Evaluation of Headache (PDF)
Effective Date: 1/1/2022		 NICU discharge guidelines (PDF)
Effective Date: 1/1/2022
 Vitamin D Testing in Children (PDF)
Effective Date: 1/1/2022
Electric Tumor Treating Fields (PDF)
Effective Date: 1/1/2022		 Non-invasive Home Ventilators (PDF)
Effective Date: 1/1/2022		 Wheelchair Seating (PDF)
Effective Date: 1/1/2022
Electromyography and Nerve Conduction Studies (PDF)
Effective Date: 1/1/2022		 Non-myeloablative Allogeneic Stem Cell Transplants (PDF)
Effective Date: 1/1/2022		 Wireless Motility Capsule (PDF)
Effective Date: 1/1/2022
Endometrial Ablation (PDF)
Effective Date: 1/1/2022		 Obstetrical Home Health Care Programs (PDF)
Effective Date: 1/1/2022		  
Essure Removal (PDF)
Effective Date: 1/1/2022		 Optic Nerve Decompression Surgery (PDF)
Effective Date: 1/1/2022		  
Evoked Potentials (PDF)
Effective Date: 1/1/2022		 Orthognathic Surgery (PDF)
Effective Date: 1/1/2022		  
Experimental Technologies (PDF)
Effective Date: 1/1/2022		 Osteogenic Stimulation (PDF)
Effective Date: 1/1/2022		  
External Ocular Photography (PDF)
Effective Date: 1/1/2022		 Outpatient Cardiac Rehabilitation (PDF)
Effective Date: 1/1/2022		  
Facet Joint Interventions (PDF)
Effective Date: 1/1/2022		 Oxygen Use and Concentrators (PDF)
Effective Date: 1/1/2022		  
Fecal incontinence treatments (PDF)
Effective Date: 1/1/2022		 Pancreas Transplant (PDF)
Effective Date: 1/1/2022		  
Ferriscan R2-MRI (PDF)
Effective Date: 1/1/2022		 Panniculectomy (PDF)
Effective Date: 1/1/2022		  
Fertility preservation (PDF)
Effective Date: 1/1/2022		 Pediatric Heart Transplant (PDF)
Effective Date: 1/1/2022		  
Fetal surgery in utero for prenatally diagnosed malformations (PDF)
Effective Date: 1/1/2022		 Pediatric Liver Transplant (PDF)
Effective Date: 1/1/2022		  
Fluorescein Angiography (PDF)
Effective Date: 1/1/2022		 Pediatric Oral Function Therapy (PDF)
Effective Date: 1/1/2022		  
Fundus Photography (PDF)
Effective Date: 1/1/2022		 Percutaneous Left Atrial Appendage Closure Device for Stroke Prevention (PDF)
Effective Date: 1/1/2022		  
Functional MRI (PDF)
Effective Date: 1/1/2022		 Physical, Occupational, and Speech Therapy Services (PDF)
Effective Date: 1/1/2022		  
Gastric Electrical Stimulation (PDF)
Effective Date: 1/1/2022		 Polymerase Chain Reaction Respiratory Viral Panel Testing (PDF)
Effective Date: 1/1/2022		  
Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing (PDF)
Effective Date: 1/1/2022		 Posterior tibial nerve stimulation for voiding dysfunction (PDF)
Effective Date: 1/1/2022
  
Gender Affirming Procedures (PDF)
Effective Date: 1/1/2022		 PROM Testing (PDF)
Effective Date: 1/1/2022
  
Genetic and Pharmacogenetic Testing (PDF)
Effective Date: 1/1/2022		 Proton and neutron beam therapies (PDF)
Effective Date: 1/1/2022
  
Gonioscopy (PDF)
Effective Date: 1/1/2022