WAC 182-55-035   Committee coverage determination.  Based on the evidence regarding safety, efficacy, and cost-effectiveness of the health technology, the committee shall:

     (1) Determine the conditions, if any, under which the health technology will be included as a covered benefit in health care programs of participating agencies by deciding that:

     (a) Coverage is allowed without special conditions because the evidence is sufficient to conclude that the health technology is safe, efficacious, and cost-effective for all indicated conditions; or

     (b) Coverage is allowed with special conditions because the evidence is sufficient to conclude that the health technology is safe, efficacious, and cost-effective in only certain situations; or

     (c) Coverage is not allowed because either the evidence is insufficient to conclude that the health technology is safe, efficacious, and cost-effective or the evidence is sufficient to conclude that the health technology is unsafe, ineffectual, or not cost-effective.

     (2) Identify whether the determination is consistent with the identified medicare decisions and expert guidelines.

     (3) For decisions that are inconsistent with either the identified medicare decisions or expert guidelines, specify the reason(s) for the decision and the evidentiary basis.

     (4) For covered health technologies, specify criteria for participating agencies to use when deciding whether the health technology is medically necessary or proper and necessary treatment.



[Statutory Authority: RCW 41.05.013, 41.05.160, and 70.14.090. 06-23-083 (Order 06-10), § 182-55-035, filed 11/13/06, effective 12/14/06.]