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.

Stereotactic Radiation Surgery (SRS) is a highly precise form of radiation therapy. It uses a single, or very limited number of, high dose(s) of radiation directed at a tumor within the central nerve system (CNS). When used outside the CNS, it is referred to as Stereotactic Body Radiation Therapy (SBRT) and is usually delivered in multiple fractions.

Coverage decision

Stereotactic Radiation Surgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) are covered benefits with conditions that are accepted on the claim.

Stereotactic Radiation Surgery (SRS) for Central Nervous System (CNS) primary and metastatic tumors is a covered benefit when the following criteria are met: CNS primary or metastatic tumors.

Patient functional status score, i.e., Karnofsky score, is greater than or equal to 50; and

Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input.

Stereotactic Body Radiation Therapy (SBRT) is covered when the following criteria are met: For cancers of spine/paraspinal structures; or

For inoperable non‐small cell lung cancer, stage 1; and

Evaluation includes multidisciplinary team analysis (e.g., tumor board), including surgical input.

All other indications are Not Covered.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed SRS & SBRT on November 16, 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:  What we're working on | Washington State Health Care Authority

Implementation of this Determination

Beginning July 15, 2013 all requests for SRS & SBRT require prior authorization.