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.
Smoking or other use of tobacco does not meet the definition of an industrial injury or occupational disease and the insurer will not accept it as a condition under the claim. However, tobacco cessation treatment may be covered as a temporary aid to recovery when it is preauthorized prior to surgery and certain criteria are met. This is based on evidence that shows tobacco cessation before surgery helps reduce post-operative complications and improve surgical outcomes.
Required Criteria for Treatment
To provide workers with the best chance of having a good surgical outcome, the insurer will cover tobacco cessation treatment for planned surgeries when all the following criteria are met:
- The worker uses tobacco product(s) (cigarettes, pipes, cigars, smokeless tobacco) on a regular basis AND
- Tobacco cessation treatment has not previously been paid on the claim, or if it has, an exception for repeat treatment has been made based on individual claim review AND
- The provider recommends tobacco cessation treatment, OR L&I’s medical treatment guideline for the surgery recommends or requires tobacco cessation treatment prior to surgery (Table 1) AND
- A worker meets the surgical criteria in L&I’s medical treatment guideline when authorization for a planned surgery is requested.
L&I Guidelines Requiring or Recommending Tobacco Cessation
- Cervical Radiculopathy *
- Lumbar spine surgery guideline *
- Shoulder Conditions: Rotator Cuff Repair *
* For all initial and repeat fusion procedures, proof of absolute nicotine cessation is required, demonstrated by two negative urine cotinine tests conducted at least one month apart, within 3 months of the request for surgery unless there is an urgent/emergent need for surgery. For initial/repeat decompression procedures or rotator cuff surgery, the department considers it best practice to abstain from nicotine for at least 4 weeks prior to surgery, as demonstrated by two negative urine cotinine tests during this time period.
Future guidelines that require or recommend tobacco cessation will be posted on the Medical Treatment Guidelines webpage as they are created.
Treatment Description and Coverage
Studies show the most effective tobacco cessation treatment includes both pharmacotherapy and behavioral therapy or counseling support.
Pharmacotherapy should start at least 4 weeks before the planned surgery and may continue for up to 12 weeks. It consists of one of the following treatments:
- Any combination of covered nicotine replacement therapies (NRT) – patches, gum or lozenges), OR
- Varenicline (brand name Chantix) oral medication OR
- Bupropion (brand name Zyban) oral medication
Limitations on Pharmacotherapy
- Nicotine nasal sprays and inhalers are not L&I approved cessation products.
- Electronic cigarettes (e.g “e-cigarettes” and “vaping”) are increasingly being used to deliver nicotine, sometimes as an aid to quitting cigarettes. There is insufficient evidence for their effectiveness and safety and they are not FDA-approved for tobacco cessation. The department does not cover these products.
- All medications must be prescribed on standard prescription forms and obtained from a pharmacy for them to be payable.
Behavioral Therapy or Counseling
Behavioral therapy or counseling on quitting tobacco may be done through multiple methods such as in-person office visits, a telephone hotline, or use of an application on an electronic device. L&I covers up to 8 sessions of in-person counseling provided by an L&I covered provider. Workers may have additional resources for behavioral therapy or counseling for tobacco cessation outside the workers’ compensation system, and if so, those services will not be covered by L&I.
Resources for Workers and Providers
- Washington State Department of Health:
- SmartQuitTM* App, which is free to anyone that lives in Washington State
- Call the Washington Department of Health Tobacco Quitline at 1-800-QUIT-NOW (1-800-784-8669).
- U.S Department of Health and Human Services: http://smokefree.gov/
- Centers for Disease Control and Prevention:
- American Lung Association: http://www.lung.org/
- American Cancer Society: http://www.cancer.org/healthy/stayawayfromtobacco/index
Billing information can be found in the Payment Policies section of L&I’s fee schedule.
CPT Codes for Tobacco Cessation Counseling are limited to a maximum of 8 units of any combination.