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.
Gene expression profile (GEP) testing analyzes the expression patterns of a number of different genes within cancer cells to predict the cancer’s aggressiveness and risk of recurrence. GEP testing has been used to help inform decisions on treatments of different cancers. These tests can lead to potential benefits, such as more appropriate treatment decisions and better patient outcomes, including avoidance of treatment-related side effects by forgoing unnecessary treatments.
GEP testing of multiple myeloma and of colon cancer tissue
Coverage Decision: Not covered
GEP testing of breast cancer tissue and of prostate cancer tissue
Coverage Decision: Covered with conditions
Conditions of Coverage
The testing is a covered at a rate of one test per twelve (12) months per index cancer and when test results will impact treatment decisions.
Oncotype DX, EndoPredict, Prosigna, and MammaPrint tests are covered for early stage 1 or 2 cancer.
- Estrogen receptor positive and HER2-NEU negative
- Lymph node negative or 1-3 lymph node(s) positive
Mammostrat and BCI tests are covered only for women with stage 1 or 2 cancer deciding about hormone therapy.
Oncotype DX and Prolaris are covered during early stage disease. Decipher is covered for men deciding between active surveillance and adjuvant radiotherapy after radical prostatectomy.
The State Health Technology Clinical Committee (HTCC) reviewed gene expression profile testing in March 2018 and finalized the determination on May 18, 2018. 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 gene expression profile testing 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).