| Coverage Decisions for Drugs |  | |
Smoking cessation
Coverage decision
This applies to State Fund and self-insurer employers.
The insurer may pay for tobacco use cessation products for spinal fusion surgery:
- On a temporary basis,
- When a physician requests the surgery for a worker, and
- All of the following criteria are met:
- The worker:
- Currently uses one or more tobacco products daily, and
- Has not failed a course of smoking cessation paid for by the insurer on the claim.
- The physician:
- Recommends a spinal fusion and the worker meets L&I guidelines for the fusion,
- Has instructed the worker to cease using tobacco products for a period of time necessary for the spinal fusion to be effective, and
- Has concluded that smoking cessation products are necessary for the worker to stop using tobacco products.
The physician and worker must sign and return an authorization letter (provided by the claim manager) acknowledging agreement with the criteria for treatment.
Timing of nicotine withdrawal relative to the spinal fusion is important. The following expectations should be considered:
- If the physician will not do surgery while the worker is using tobacco products, the worker must stop using these products for 90 days prior to the surgery to be approved.
- There is an expectation that the worker remains nicotine free for 180 days after the spinal fusion.
- Upon request by the physician, the insurer may require, as a condition of authorizing the spinal fusion, the worker have a urine test to prove that no nicotine metabolites are present.
The worker must use L&I-approved tobacco use cessation products. Currently approved products include:
- Zyban (bupropion HC1),
- Chantix (varenicline Tartrate),
- Nicotine patches,
- Nicotine gum,
- Nicotine lozenges, and
- A combination of Zyban and nicotine patches, gum or lozenges.
Nicotine nasal sprays and inhalers are not approved cessation products.
The following limitations apply to the use of these products:
- Up to 12 months use of Zyban, 6 months before and after surgery,
- Up to 6 months use of Chantix, 3 months before and after surgery, and
- 90 days use of nicotine patches, gum or lozenges, 3 months before surgery.
- Authorization may be discontinued if there is evidence that the worker is smoking 2 months after beginning use of smoking cessation products.
Authorization to pay for tobacco use cessation products is done on a 1 time only basis per claim. The insurer may pay for tobacco use cessation products during one 3-12 month period. If the worker stops using the products and then restarts, the insurer will not pay for smoking cessation products again on that claim.
What do I need to do to get tobacco use cessation products approved on a claim?
The insurer's claim manager will need to pre-approve tobacco use cessation products. The physician must show that the worker is a candidate for spinal fusion.
State Fund claims
To initiate the review for the spinal fusion, the physician must call the Utilization Review vendor:
Qualis Health
Toll free: 1-800-541-2894
Seattle: 206-366-3360
Fax: 1-877-665-0383 or 206-366-3378
The physician informs Qualis Health that the worker needs to stop smoking and needs tobacco use cessation products to do so. Qualis Health will initiate the spinal fusion review and ask the physician to call the claim manager for authorization of the smoking cessation products. Only the claim manager can authorize purchase of the products.
To finish the spinal fusion review, the physician's office calls and tells Qualis Health the surgery date. Surgery coincides with the worker being off all nicotine products for at least 90 days.
Self-insurer claims
Contact the self-insurer directly.
For more information:
Contact information.
WAC 296-20-055 - Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.
