Coverage of Conditions and Treatments (Coverage Decisions)
There are two general types of stent: bare metal stents (BMS) and drug eluting stents (DES). DES are essentially BMS that have been coated with a polymer containing an anti-proliferative drug, which inhibits vascular smooth cell proliferation and migration to prevent the neo-intimal hyperplasia. For patients being treated for coronary artery disease (CAD), consideration of revascularization with cardiac stents is based on the clinical presentation, the severity of the angina, the extent of ischemia and presence or absence of other prognostic factors. For injured workers, the procedure may be covered only for care of a condition accepted on or related to the claim.
Coverage conditions:
Either drug eluting or bare metal cardiac stents are a covered benefit when cardiac stents are indicated for treatment.
For patients being treated for stable angina, cardiac stents are a covered benefit with conditions:
- Angina refractory to optimal medical therapy, and
- Objective evidence of myocardial ischemia
Background information
This technology was originally reviewed by the State Health Technology Clinical Committee (HTCC) in May 2009 and was selected for re-review based on new literature identified and changing standards of practice. HTCC reviewed cardiac stents in January 15, 2016. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that cardiac stents are a covered benefit with conditions. Complete information on this HTCC determination is available here: 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 applicable to L&I. Any coverage for humanitarian or investigational treatment would be considered per WAC 296-20-02850.
Implementation of the Coverage Decision
All requests for cardiac stents require prior authorization. The procedure 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).