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.
Updated and effective 11/01/2023
Stereotactic Radiation Surgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are covered benefits with conditions.
Conditions of coverage:
Stereotactic Radiation Surgery (SRS)
- SRS for Central Nervous System (CNS) primary and metastatic tumors is a covered benefit when the following criteria are met:
- Patient functional status score is greater than or equal to 50 using the Karnofsky scoring method; and
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
Stereotactic Body Radiation Therapy (SBRT)
- SBRT is a covered benefit with conditions for treatment of cancers of spine/paraspinal structures, localized prostate cancer, non-small cell and small cell lung cancer, pancreatic adenocarcinoma, oligometastatic disease, hepatocellular carcinoma, and cholangiocarcinoma.
- Cancers of spine/paraspinal structures:
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Localized Prostate cancer for:
- Very low, low, and intermediate risk prostate cancer, as defined by NCCN based on stage, Gleason score, and PSA level, and
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Non-Small Cell Lung Cancer (NSCLC) for:
- Stage I and Stage II (node negative), and
- Tumor is deemed to be unresectable, or patient is deemed too high risk, or declines operative intervention, and
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Small Cell Lung Cancer (SCLC) for:
- Stage I and Stage II (node negative) and at least one of the following:
- Tumor is deemed to be unresectable.
- Patient is deemed too high risk for surgery.
- Operative intervention declined, and
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Pancreatic Adenocarcinoma for:
- Non-metastatic disease and is either deemed not a candidate for induction chemotherapy or has already undergone induction chemotherapy and at least one of the following:
- Tumor is deemed to be unresectable.
- Patient is deemed too high risk for surgery.
- Operative intervention declined.
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Non-metastatic disease and is either deemed not a candidate for induction chemotherapy or has already undergone induction chemotherapy and at least one of the following:
- Oligometastatic disease for:
- When each of the following conditions are met:
- Five or fewer total metastatic lesions (maximum 3 per organ)
- Controlled primary tumor
- Life expectancy greater than 6 months
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- When each of the following conditions are met:
- Hepatocellular carcinoma for:
- When each of the following conditions are met:
- Liver confined disease
- Five or fewer lesions
- Life expectancy greater than 6 months
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- When each of the following conditions are met:
- Cholangiocarcinoma for:
- Non-metastatic disease and at least one of the following:
- Tumor is deemed to be unresectable.
- Patient is deemed too high risk for surgery.
- Operative intervention declined.
- Evaluation includes multidisciplinary team analysis (e.g., tumor board) including a surgical specialist and radiation oncologist.
- Non-metastatic disease and at least one of the following:
- Cancers of spine/paraspinal structures:
- SBRT is not a covered benefit for treatment of primary bone, head and neck, adrenal, melanoma, Merkel cell, breast, ovarian, and cervical cancers
Background Information
The State Health Technology Clinical Committee (HTCC) reviewed SRS & SBRT in November 2012. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that SRS & SBRT are covered benefits with conditions. Complete information on this HTCC determination is available here: Health technology reviews.
In May 2023, the HTCC reviewed new evidence on SBRT and made a new coverage determination in July 2023. This L&I coverage decision includes both the new determination on SBRT and the determination on SRS made in 2013.
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).