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.
Proton beams have less scatter radiation than other sources of energy (e.g., gamma rays and x-rays). Because of this feature, proton beam can deliver high doses of radiation to the tumor while limiting the “scatter” dose received by surrounding tissues. Proton beam therapy is used to treat tumors located deep within the body and close to critical organs and body structures.
Proton beam therapy is a covered benefit for children/adolescents less than 21 years old.
Proton beam therapy is a covered benefit with conditions for individuals 21 years old and older.
Conditions of Coverage:
For individuals 21 years old and older proton beam therapy is a covered benefit with conditions for the following primary cancers:
- Head/ neck
- Hepatocellular carcinoma
- Brain/ spinal
Other primary cancers where all other treatment options are contraindicated after review by a multidisciplinary tumor board.
Proton beam therapy is not covered for all other conditions.
The technology was first reviewed in 2014 and re-reviewed in May 2019 by the State Health Technology Clinical Committee (HTCC). The committee expanded the coverage to include additional cancer types based on the recent evidence reviewed, and finalized the determination in July 2019. 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 proton beam therapy 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).