Medicare Prior Authorization Medical Clinical Policies
Medical Clinical Policies
- CPG Grid Adopted Clinical Practice and Preventive Health Guidelines (PDF)
- MC.CP.CPC.05 Medical Necessity Criteria (PDF)
- MC.CP.MP.22 Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (PDF)
- MC.CP.MP.31 Cosmetic and Reconstructive Procedures (PDF)
- MC.CP.MP.57 Lung Transplantation (PDF)
- MC.CP.MP.69 Intensity Modulated Radiation Therapy (IMRT) (PDF)
- MC.CP.MP.101 Donor Lymphocyte Infusion (PDF)
- MC.CP.MP.107 Durable Medical Equipment and Orthotics and Prosthetics Guidelines (PDF)
- MC.CP.MP.108 Allogeneic Hematopoietic Cell Transplants for β-Thalassemia (PDF)
- MC.CP.MP.166 Sacroiliac Joint Interventions for Pain Management (PDF)
- MC.CP.MP.170 Peripheral Nerve Blocks and Ablation of Peripheral Nerves for Pain Management (PDF)
- MC.CP.MP.184 Home Ventilators (PDF)
- MC.CP.MP.185 Skin and Soft Tissue Substitutes (PDF)
- MC.CP.MP.190 Outpatient Oxygen Use (PDF)
- MC.CP.MP.246 Pediatric Kidney Transplant (PDF)
- MC.CP.MP.247 Transplant Service Documentation Requirements (PDF)
- MC.CP.MP.248 Facility-based Sleep Studies for Obstructive Sleep Apnea (PDF)
- MC.CP.MP.249 Allogeneic Hematopoietic Progenitor Cell Therapy (PDF)
- MC.CP.MP.250 Lantidra (donislecel): Allogeneic Pancreatic Islet Cellular Therapy (PDF)
Concert Genetics Policies
The Concert Genetics Clinical Criteria Support (PDF) document explains the evidence base for the Concert Genetics policies and the balance
of the benefits vs. the risks of the criteria.
- V2.2025 Concert Genetic Testing Oncology: Algorithmic Assays (PDF)
- V2.2025 Concert Genetic Testing Oncology: Cancer Screening and Surveillance (PDF)
- V2.2025 Concert Genetic Testing Oncology: Hematologic Malignancy (PDF)
- V2.2025 Concert Genetic Testing Oncology: Solid Tumor Molecular Diagnostics (PDF)
- V2.2025 Concert Genetic Testing: Cardiovascular (PDF)
- V2.2025 Concert Genetic Testing: Dermatology (PDF)
- V2.2025 Concert Genetic Testing: Endocrinology (PDF)
- V2.2025 Concert Genetic Testing: Gastroenterology (PDF)
- V2.2025 Concert Genetic Testing: General Approach to Genetic and Molecular Testing (PDF)
- V2.2025 Concert Genetic Testing: Hematology (PDF)
- V2.2025 Concert Genetic Testing: Hereditary Cancer (PDF)
- V2.2025 Concert Genetic Testing: Identity and Forensics (PDF)
- V2.2025 Concert Genetic Testing: Immunology and Rheumatology (PDF)
- V2.2025 Concert Genetic Testing: Multisystem Genetic Conditions (PDF)
- V2.2025 Concert Genetic Testing: Nephrology (PDF)
- V2.2025 Concert Genetic Testing: Neurology (PDF)
- V2.2025 Concert Genetic Testing: Nutrition and Metabolism (PDF)
- V2.2025 Concert Genetic Testing: Ophthalmology (PDF)
- V2.2025 Concert Genetic Testing: Orthopedics (PDF)
- V2.2025 Concert Genetic Testing: Otolaryngology (PDF)
- V2.2025 Concert Genetic Testing: Preimplantation Genetic Testing (PDF)
- V2.2025 Concert Genetic Testing: Prenatal and Preconception Carrier Screening (PDF)
- V2.2025 Concert Genetic Testing: Prenatal Diagnosis (PDF)
- V2.2025 Concert Genetic Testing: Prenatal Screening (PDF)
- V2.2025 Concert Genetic Testing: Respiratory (PDF)
- V2.2025 Concert Genetic Testing: Toxicology and Pharmacogenetics (Version A) (PDF)
- V2.2025 Concert Genetic Testing: Toxicology and Pharmacogenetics (Version B) (PDF)
- V2.2025 Concert Genetic Testing: Transplant (PDF)
New Century Health Cardiology Policies
New Century Health cardiology policies are applicable to the following Wellcare Medicare plans as of the dates noted below:
- July 1, 2023: CT, FL, HI, KY, LA, MA, MI, NC, RI, VT, NH, OH, GA, MO, TX, and WA
- October 1, 2023: AL, MS, NJ, SC, IL, and TN
- January 1, 2025: ME and IA