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.
Fecal microbiota transplantation (FMT) is a procedure whereby donor fecal matter is placed into a patient’s gastrointestinal system in order to recolonize it with normal gut bacteria. The most common use for FMT is treatment of Clostridium difficile infections, particularly those that are recurrent or resistant to standard antibiotic therapy.
Conditions of Coverage
- Patients with Clostridium difficile infection who have failed an appropriate course of antibiotic therapy.
- FMT is not covered for treatment of inflammatory bowel disease, such as ulcerative colitis or regional enteritis.
- FMT is considered investigational for any other condition.
This technology was reviewed by the State Health Technology Clinical Committee (HTCC) in November 2016 and the determination was finalized on January 20, 2017. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that FMT is a covered benefit with conditions. 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 Decision
All requests for FMT 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).