Coverage of Conditions and Treatments (Coverage Decisions)
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
See Treatment Guidelines and Resources for additional information.
* Artificial Disc Replacement is the same as Total Disc Arthroplasty (TDA)
Artificial disc replacement is a potential alternative procedure to cervical fusion in patients with radiculopathy and/or myelopathy secondary to degenerative disc disease. The most recent evidence, however, does not favor ADR as a treatment for lumbar degenerative disc disease.
Coverage Decision: Not covered
Lumbar artificial disc replacement is not a covered benefit.
Coverage Decision: Covered with conditions
Conditions of coverage:
Cervical artificial disc replacement is covered for accepted conditions when the following criteria are met:
- Patients must meet FDA approved indications for use and not have any contraindications. FDA approval is device specific but includes.
- Skeletally mature patients
- Disc replacement following one- or two-level discectomy for intractable symptomatic radiculopathy or myelopathy confirmed by patient findings and imaging.
- Patients must have advanced imaging and clinical evidence of corresponding nerve root or spinal cord compression and have failed or be inappropriate for non-operative care. For two-level procedures, objective evidence of radiculopathy, myelopathy or spinal cord compression at two consecutive levels is required.
For detailed criteria, please refer to the L&I medical treatment guideline Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy.
The State Health Technology Clinical Committee (HTCC) originally reviewed ADR in October 2008, and their decision to cover ADR was adopted by L&I in March 2009. The Industrial Insurance Medical Advisory Committee (IIMAC) subcommittee for cervical spinal surgery drafted a new guideline, Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy, which includes two-level cervical ADR. The guideline was adopted in September 2014.
The HTCC re-reviewed the ADR technology in January 2017 and in March 2017 finalized their determination to cover cervical ADR, including two-level ADR with conditions, but not cover lumbar ADR. Complete information on this HTCC determination is available at: What we're working on | Washington State Health Care Authority
In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850. Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).
Implementation of the Coverage Determination
All requests for ADR require prior authorization. The service may be covered only for care of a condition accepted on or related to the claim.
For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).