Coverage decision

Discography in the assessment of chronic low back pain or lumbar degenerative disc disease is not covered.

Discography requires prior authorization for patients with any other condition(s) including the following:

• Radiculopathy
• Functional neurologic deficits (motor weakness or EMG findings of radiculopathy)
• Spondylolisthesis (>Grade 1)
• Isthmic spondylolysis
• Primary neurogenic claudication associated with stenosis
• Fracture, tumor, infection, inflammatory disease
• Degenerative disease associated with significant spinal deformity

Information on how to request authorization review is included below.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed discography on February 15, 2008. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that discography is not covered for patients with chronic low back pain or lumbar degenerative disc disease.

Complete information on this HTCC determination is available here: http://www.hta.hca.wa.gov/discography.html

Implementation of this Determination

Beginning June 15, 2008 all requests for discography require prior authorization and will be reviewed by L&I’s utilization review (UR) vendor (Qualis) for State Fund or a nurse consultant for the Crime Victims Compensation Program.

For State Fund Claims

All requests for discography require prior authorization and will be reviewed by L&I’s utilization review ( UR) vendor (Qualis).

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact Qualis Health by one of the following ways:

• Web Qualis Health’s preferred method of submitting UR requests is via a secure, internet application called iExchange. For more information or to schedule a training session, please go to the Qualis Health web page at http://www.qualishealth.org/cm/washington-landi/web-based_um_request.cfm.
• Phone: (800) 541-2894 (toll free) or (206) 366-3360
• Fax: (877) 665-0383 (toll free) or (206) 366-3378

For Crime Victims:

To request a review for an inpatient hospitalization or an outpatient procedure that requires UR, please contact the nurse consultant by one of the following modes of transmission: fax to (360) 902-5333 or call (360) 902-4896.

For Self-Insured Claims

For self-insured claims, contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to: http://www.lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/FindEmps/Default.asp

Billing Codes

Provider Bulletin 08-01 Discography (145 KB PDF).
Health Care Authority's Health Technology Assessment Program site.

For more information:
Contact information.

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