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.
PET may be used as an imaging tool for staging of lymphoma after histological diagnosis, for interim evaluation, and for end‐of-treatment assessment.
PET scans (i.e. PET with computed tomography or PET/CT) for lymphoma is a covered benefit with conditions.
Conditions of Coverage
An initial staging scan is covered followed by up to three (3) scans per active occurrence of lymphoma:
- When used to assess a response to chemotherapy, scans should not be done any sooner than three (3) weeks after completion of any chemotherapy cycle.
- When used to assess response to radiation therapy, scans should not be done any sooner than eight (8) weeks after completion of radiation or combined chemotherapy and radiation therapy.
Relapse: PET scan is covered when relapse is suspected in the presence of clinical symptoms or other imaging findings suggestive of recurrence.
Surveillance: PET scan is not covered for surveillance.
Background Policy Information
The State Health Technology Clinical Committee (HTCC) first reviewed PET scans for lymphoma in 2011. The committee reviewed the technology again in November 2018 and finalized the determination on January 18, 2019. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that PET scans for lymphoma 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 Determination
All requests for PET scan for lymphoma 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).