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WellMed Networks Inc. is a 501(a) Texas not for profit corporation and performs delegated services on behalf of Medicare Advantage health plans for utilization management, claims, care management, credentialing and network management.

WellMed Networks Inc. and its affiliates use evidence-based clinical guidelines and medical literature from nationally recognized sources to develop medical coverage policies. The medical coverage policies outline the criteria our clinicians use to determine if a procedure is “medically necessary” and serve as a reference for WellMed delegated Medicare Advantage members, participating physicians and other health care professionals.

There are times when a Medicare statute, regulation, NCD or LCD does not fully establish coverage criteria. When that happens, CMS allows MA plans (and their delegates) to create and use our own internal coverage criteria policies. We must base those policies on current evidence in widely used treatment guidelines or clinical literature. And they must be approved by the health plan’s MMC committee and made publicly accessible. (42 CFR 422.101(6) (i)):

(i) Coverage criteria not fully established. Coverage criteria are not fully established when:

A. Additional, unspecified criteria are needed to interpret or supplement general provisions in order to determine medical necessity consistently. The MA organization must demonstrate that the additional criteria provide clinical benefits that are highly likely to outweigh any clinical harms, including from delayed or decreased access to items or services;

We will only use an internal coverage policy for a customer’s specific condition when a Medicare policy, an NCD or LCD is not fully established. CMS policies are not fully established when any of the following apply:

  • More criteria are needed to interpret or support general provisions in an NCD, LCD or other Medicare coverage policy; or
  • There is flexibility allowed in an NCD or LCD; or
  • There is no applicable NCD or LCD to decide medical necessity; or
  • There is no applicable Local Coverage Article (used with an LCD) to decide medical necessity; or
  • A Medicare policy does not address the customer’s specific condition for the request under review; or
  • A Medicare policy does not include specific coverage criteria. A Medicare policy may have broad guidelines, but it may not have enough detail to decide if the request is medically necessary.

MCG 

MCG care guidelines are the intellectual property of MCG Health and access is strictly controlled. Users are not able to distribute any MCG content without the permission of MCG. By following these instructions, you will have access to view MCG care guidelines online.

Step 1 disclaimer: Select the “MCG Care Guidelines” link to where you will land on MCG disclaimer page. You must check the “Accept Terms and Conditions” box and select the “Accept and Proceed” button to continue to the next page.

Step 2 user information: Next you will be required to enter your first name, last name and to select the button the most closely aligns with your interest in MCG care guidelines. Then select “Next”.

Step 3 contact information: MCG will ask for your preferred way of receiving a verification code. Select from text message, email or telephone call then select “Next”.

Step 4 access code: Enter the code received via your preferred method.

Step 5: Click on the ► desired product to be a shown a list of MCG care guidelines selected for the client’s program.

Step 6: Click on the guidelines you wish to review. Copy/pasting, printing, or other methods of duplication are not allowed. Once finished, Select “Back to Guidelines” list or close your tab.

Please click on the link to access the MCG clinical guidelines: WellMed 

Please click on the links below to access approved internal criteria:

NCCN link: Login (nccn.org)

Date: 4/4/24