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.

Archived Coverage Decisions.

See Treatment Guidelines and Resources for additional information.

Upper endoscopy is a diagnostic procedure. Upper endoscopy involves the insertion of a thin flexible tube down a patient's throat and esophagus. The endoscope has a light and camera attached allowing a doctor to visually inspect the esophagus for abnormalities and to take small pieces of tissue (biopsy) if needed.

Note: Upper endoscopy may be used only for care of a condition accepted on the claim. Upper endoscopy is an invasive procedure. GERD and GI symptoms are unlikely to be related to any occupational injury or disease and are therefore not expected to be accepted conditions on an L&I claim.

Conditions of Coverage

Adults with initial presenting complaints of upper GI symptoms or symptoms consistent with GERD

• Failure of adequate trial of medical treatment to improve or resolve symptoms (recurrence of symptoms after initial treatment indicates treatment failure), or;
• Presence of alarm symptoms: Persistent dysphagia or odynophagia;
  • Persistent vomiting of unknown etiology;
  • Evaluation of epigastric mass;
  • Confirmation and specific histological diagnosis of radiologically demonstrated lesions;
  • Evaluation for chronic blood loss and iron deficiency anemia when an upper gastrointestinal source is suspected or when colonoscopy results are negative;
  • Progressive unintentional weight loss.

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed upper endoscopy for GERD and GI symptoms on May 18, 2012. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that upper endoscopy for GERD and GI symptoms is a covered benefit with conditions. Complete information on this HTCC determination is available here: What we're working on | Washington State Health Care Authority.

Implementation of the Determination

Upper endoscopy may be used only for care of a condition accepted on the claim. Upper endoscopy is an invasive procedure. GERD and GI symptoms are unlikely to be related to any occupational injury or disease and are therefore not expected to be accepted conditions on an L&I claim. All requests require prior authorization.