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.
Coverage decision: Not Covered (Effective date: March 7, 2016)
Lumbar fusion for degenerative disc disease (DDD) uncomplicated by comorbidities is not a covered benefit. The decision is based on a Health Technology Clinical Committee (HTCC) coverage determination finalized on January 15, 2016. The population addressed in this decision includes individuals >17 years of age with chronic (3 or more months) lumbar pain and uncomplicated DDD. The following conditions are excluded from this decision: radiculopathy, spondylolisthesis (>Grade 1) or severe spinal stenosis, as well as acute trauma or systemic disease affecting the lumbar spine (e.g., malignancy).
The HTCC reviewed the evidence on lumbar fusion for patients with uncomplicated DDD on November 20, 2015. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that lumbar fusion for uncomplicated DDD is not a covered benefit. 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 federal or state statutes or regulations and that the Department cannot provide reimbursement under any Department policies regarding experimental or investigational treatment, under a clinical investigation approved by an institutional review board, or as a health technology that has a humanitarian device exemption from the federal food and drug administration.
Lumbar fusion for patients with conditions other than uncomplicated DDD is addressed in Lumbar Fusion Guideline (Arthrodesis).