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Wellcare (Centene): Medicare Advantage denial & appeal rates
Centene Corporation / Wellcare
In 2024, Wellcare (Centene) denied about 11.9% of the prior-authorization requests it reviewed. When members appealed, 95.3% of those denials were overturned — yet only 7.5% of denials were appealed at all. ~81% of appealed MA prior-authorization denials are overturned, so a denial is rarely the final word.
Wellcare (Centene)’s posted coverage policies
Insurers must post the medical policies they use to decide coverage. These are the ones most relevant to lab, imaging, and facility denials — quote the matching policy in your appeal.
| Service category | Policy | Updated |
|---|---|---|
| Advanced imaging (MRI/CT) | not located as standalone Wellcare CCG | — |
| PET / oncologic imaging | not located as standalone CCG | — |
| Skilled nursing facility (SNF) | not located | — |
| Inpatient rehab facility (IRF) | not located | — |
| Home health | not located | — |
| DME (general) | Durable Medical Equipment and Orthotics and Prosthetics Guidelines (MC.CP.MP.107) | on PDF (not opened) |
| CPAP/PAP & supplies | Facility-based Sleep Studies for OSA (MC.CP.MP.248) - covers CPAP/BiPAP titration | 12/25 (verified) |
| Oxygen / respiratory | Outpatient Oxygen Use (MC.CP.MP.190); Home Ventilators (MC.CP.MP.184) | on PDF (not opened) |
| Spine surgery / fusion | not located as standalone CCG | — |
| Epidural / facet injections | Sacroiliac Joint Interventions (MC.CP.MP.166); Peripheral Nerve Blocks & Ablation (MC.CP.MP.170) | on PDF (not opened) |
| Cataract surgery | not located | — |
| Anti-VEGF / intravitreal (Eylea/Avastin) | not located as medical CCG | — |
| Behavioral health / inpatient psych | not located as standalone CCG | — |
| Skin substitutes / CTPs | Skin and Soft Tissue Substitutes for DFU and VLU (MC.CP.MP.185) | on PDF (not opened) |
| Oncology / chemotherapy drugs | not located on medical index | — |
| Knee / hip arthroplasty | not located as standalone CCG | — |
| Bariatric surgery | not located as standalone CCG | — |
| Sleep studies | Facility-based Sleep Studies for OSA (MC.CP.MP.248) | 12/25 (verified) |
| Genetic / molecular testing | Concert Genetics: General Approach to Genetic and Molecular Testing (+ ~26 sub-panels) | V1.2025 |
| Hospice | not located | — |
Wellcare (Centene)’s CMS prior-authorization metrics posting →
Denied by Wellcare (Centene)? Don’t pay a bill you may not owe.
Appeals win far more often than people expect. See how the deadlines and the process work, or fast-track a rehab/nursing discharge.
Insurer / contract level. Medicare does not publish per-plan denial rates. Rates are 2024 prior-authorization determinations; data as of July 2026. Notes: Highest overturn rate (95.3%; prose 95.5%). KFF prose cites 12.3% denial (vs 11.9% chart dataset) - flagged. Enrollment share not in 2026 KFF top-6 table (>1M MA enrollees). Posting = per-state .ashx PDFs; CA H5087 CY2025 std denial = 2.80%… Informational only — not medical, legal, or billing advice.