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.
A number of non-pharmacologic neuromodulatory treatments for treatment- resistant depression have been developed and tested clinically, such as:
- Electroconvulsive Therapy (ECT) that involves delivering electrical pulses to the brain via electrode pads positioned on the scalp above mood centers in the brain. These pulses cause an epileptic seizure, which results in global cerebral stimulation;
- repetitive Transcranial Magnetic Stimulation (rTMS) that is a noninvasive technique involving the generation of a magnetic field that penetrates the skull and induces low-level electric currents in underlying tissue, thereby altering local neuronal function without inducing seizure;
- transcranial Direct Current Stimulation (tDCS) that is a noninvasive neurostimulation method that delivers low-intensity electrical currents via 2 scalp electrodes to the cerebral cortex; and
- Deep Brain Stimulation (DBS) that requires the implantation of quadripolar electrodes, which deliver electrical current directly into the brain.
Conditions of Coverage
Electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are covered benefits for workers with a unipolar or bipolar diagnosis (excluding adjustment disorder) if the following criteria are met:
- The worker failed two trials of different classes of anti-depressant drugs at maximum tolerated dose for 4-12 weeks; AND
- The worker complied with the prescribed treatment sufficiently for the provider to determine the trials failed; OR
- The trials failed because of early termination due to adverse events or reactions.
The following treatments are NOT covered:
- Transcranial direct current stimulation (tDCS)
- Deep brain stimulation (DBS)
Background Policy Information
The State Health Technology Clinical Committee (HTCC) reviewed nonpharmacologic treatments for treatment-resistant depression on March 21, 2014. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that only certain treatments are covered benefit. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.
Implementation of the Determination
Electroconvulsive therapy and repetitive transcranial magnetic stimulation may be used only for care of a condition accepted on the claim. All requests require prior authorization