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.
The implantation of an FDA-approved diaphragmatic/phrenic nerve stimulator is a covered benefit for selected injured workers with partial or complete respiratory insufficiency due to upper cervical spinal cord injury, as an alternative to mechanical ventilation.
Conditions of Coverage
- The injured worker has ventilatory failure due to upper cervical spinal cord injury; AND
- Cannot breathe spontaneously for 4 continuous hours or more without use of a mechanical ventilator; AND
- The diaphragm can be stimulated either directly or through the phrenic nerves to generate sufficient movement to accommodate independent breathing without the support of a ventilator for at least 4 continuous hours a day; AND
- The injured worker has normal chest wall anatomy and normal lung function; AND
- The injured worker has a normal cognitive function and the motivation to undertake the rehabilitation and training program associated with the use of the device.
All requests for diaphragm pacing require prior authorization.
For billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).