CurrentConnectiCarePolicy C12971-C

Nuedexta (dextromethorphan/quinidine) Coverage for Pseudobulbar Affect

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Prior authorization coverage of oral Nuedexta for members with pseudobulbar affect secondary to a neurological condition, including requirements for clinical eligibility, prescriber qualifications, age, documentation, dosing, continuation, and authorization duration.

Policy Summary

PayerConnectiCare

PolicyNuedexta (dextromethorphan/quinidine) Coverage for Pseudobulbar Affect

Policy CodePolicy C12971-C

Change TypeNo material clinical or coverage changes

Effective DateMay 22, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of pseudobulbar affect secondary to a neurological condition and a baseline CNS-LS score of at least 13 for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥13Baseline CNS-LS

18+Minimum age

85%Continuation adherence

3 monthsInitial authorization

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CurrentConnectiCarePolicy C12971-C

Nuedexta (dextromethorphan/quinidine) Coverage for Pseudobulbar Affect

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Policy Summary

PayerConnectiCare

PolicyNuedexta (dextromethorphan/quinidine) Coverage for Pseudobulbar Affect

Policy CodePolicy C12971-C

Change TypeNo material clinical or coverage changes

Effective DateMay 22, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of pseudobulbar affect secondary to a neurological condition and a baseline CNS-LS score of at least 13 for prior authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥13Baseline CNS-LS

18+Minimum age

85%Continuation adherence

3 monthsInitial authorization

12 monthsContinuation authorization

Coverage Criteria

Initial Therapy

Covered for initial therapy when ALL of the following are met.

Initial therapy

PBA diagnosis: Documentation of a diagnosis of pseudobulbar affect (PBA) secondary to a neurological condition, such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), stroke, or traumatic brain injury (TBI), characterized by involuntary, sudden, and frequent episodes of laughing and/or crying typically occurring out of proportion or incongruent to the underlying emotional state.
Disease severity assessment: Documentation of a baseline Center for Neurologic Study-Lability Scale (CNS-LS) score of at least 13.≥13
See Appendix 1.
Contraindication review: The prescriber attests, or the clinical reviewer finds, that the member does not have any FDA-labeled contraindications that have not been addressed by the prescriber in the submitted documentation.

Continuation Therapy

Covered for continuation therapy when ALL of the following are met.

Continuation therapy

Adherence to therapy is at least 85% of the time as verified by the prescriber or the member's medication fill history, OR adherence is less than 85% because surgery or treatment of an infection caused temporary discontinuation.≥85% unless stated exception
Safety and tolerability: The prescriber attests, or the clinical reviewer finds, that there is no evidence of intolerable adverse effects or drug toxicity.
Clinical response: Documentation demonstrates a positive clinical response, including low disease activity and/or improvement in the condition's signs and symptoms.
Reassessment:

Pseudobulbar Affect

FDA-approved use

Covered indication: Nuedexta is indicated for the treatment of pseudobulbar affect (PBA).

PBA is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that typically occur out of proportion or incongruent to the underlying emotional state.

Coverage is precluded when an FDA-labeled contraindication is present and has not been addressed in the submitted documentation. Contraindications include concomitant quinidine, quinine, or mefloquine; prior quinidine-, quinine-, or mefloquine-induced thrombocytopenia, hepatitis, or other hypersensitivity reactions; known dextromethorphan hypersensitivity; MAOI use or use within 14 days after stopping an MAOI; prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, or heart failure; complete atrioventricular block without an implanted pacemaker or high risk of complete atrioventricular block; and concomitant use of drugs that both prolong the QT interval and are metabolized by CYP2D6, such as thioridazine or pimozide.

All uses of Nuedexta other than treatment of pseudobulbar affect are considered experimental/investigational and are subject to the applicable off-label policy.

Nuedexta is contraindicated with quinidine, quinine, or mefloquine; a history of quinidine-, quinine-, or mefloquine-induced thrombocytopenia, hepatitis, or other hypersensitivity reactions; known hypersensitivity to dextromethorphan; MAOI use or use within 14 days after stopping an MAOI; prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, or heart failure; complete atrioventricular block without an implanted pacemaker or high risk of complete atrioventricular block; and concomitant use of drugs that both prolong the QT interval and are metabolized by CYP2D6, including thioridazine or pimozide.

Clinical Thresholds

Baseline CNS-LS Score

Minimum baseline scoreAt least 13

AssessmentCenter for Neurologic Study-Lability Scale (CNS-LS)

Coverage stageInitial therapy

Continuation Adherence

Minimum adherenceAt least 85%

VerificationPrescriber verification or member medication fill history

ExceptionAdherence below 85% is allowed when surgery or treatment of an infection causes temporary discontinuation

Authorization and Documentation Requirements

Prior Authorization

Initial Prior Authorization

Prior authorization is required for Nuedexta. The initial request must establish the covered diagnosis, baseline CNS-LS score, age, qualified prescriber, and absence of unaddressed FDA-labeled contraindications.

Pseudobulbar affect (PBA) must be secondary to a neurological condition, such as ALS, MS, stroke, or traumatic brain injury, and involve involuntary, sudden, frequent laughing and/or crying episodes that are typically out of proportion or incongruent with the underlying emotional state.
Submit a baseline Center for Neurologic Study-Lability Scale (CNS-LS) score of at least 13.
The member must be 18 years of age or older.
The drug must be prescribed by, or in consultation with, a neurologist or psychiatrist.
The prescriber must attest, or the clinical reviewer must determine, that no FDA-labeled contraindication remains unaddressed in the submitted documentation.

Prior Authorization

Authorization Duration

Initial authorization is approved for 3 months; continuation authorization is approved for 12 months when continuation criteria are met.

Clinical Background

Pseudobulbar affect is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are typically out of proportion to or incongruent with the underlying emotional state. It occurs secondary to a neurological condition, such as ALS, multiple sclerosis, stroke, or traumatic brain injury.

Key Definitions

Pseudobulbar Affect (PBA)

ConditionPseudobulbar affect (PBA)

Characteristic symptomsInvoluntary, sudden, and frequent episodes of laughing and/or crying

Emotional relationshipEpisodes typically occur out of proportion to or incongruent with the underlying emotional state

CNS-LS

Full nameCenter for Neurologic Study-Lability Scale

PurposeAssessment of emotional lability, including involuntary crying and laughing

Required baseline score

Initial Therapy

Initial therapy is covered when ALL of the following are met.

Initial therapy

PBA diagnosis: Documented pseudobulbar affect (PBA) secondary to a neurological condition, such as amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), stroke, or traumatic brain injury (TBI), characterized by involuntary, sudden, and frequent episodes of laughing and/or crying typically occurring out of proportion or incongruent to the underlying emotional state.
CNS-LS: A baseline Center for Neurologic Study-Lability Scale (CNS-LS) score is documented at 13 or higher.≥13
See Appendix 1.
Contraindication assessment: The prescriber attests, or the clinical reviewer determines, that the member does not have any FDA-labeled contraindications that have not been addressed by the prescriber in the submitted documentation.

Continuation Therapy

Continuation therapy requires ALL of the following.

Continuation therapy

Adherence to therapy is at least 85% of the time as verified by the prescriber or the member's medication fill history, OR adherence is less than 85% because surgery or treatment of an infection caused temporary discontinuation.≥85% unless stated exception
No intolerable toxicity: There is no evidence of intolerable adverse effects or drug toxicity, as attested to by the prescriber or determined by the clinical reviewer.
Positive response: Documentation demonstrates a positive clinical response, including low disease activity and/or improvement in the condition's signs and symptoms.

Nuedexta Dosing and Quantity Limits

Nuedexta Initial Dose

DrugNuedexta

Starting dose1 capsule daily for 7 days

PhaseInitial dosing

Nuedexta Maintenance Dose

DrugNuedexta

Maintenance dose2 capsules per day

Administration1 capsule every 12 hours

Site of Care and Administration

Billing Rule

Use the pharmacy benefit for home oral therapy

Oral medication is recommended for pharmacy benefit coverage and patient self-administration. Nuedexta is administered by the oral route.

Use pharmacy benefit coverage for the oral medication.
Plan for patient self-administration at home.

Policy Summary

PayerConnectiCare

PolicyNuedexta (dextromethorphan/quinidine) Coverage for Pseudobulbar Affect

Policy CodePolicy C12971-C

Change TypeNo material clinical or coverage changes

Effective DateMay 22, 2026

Next Review DateApr 1, 2027

Key ActionSubmit documentation of pseudobulbar affect secondary to a neurological condition and a baseline CNS-LS score of at least 13 for prior authorization.

SourceLink

On This Page

Documentation shows periodic reassessment of the medical necessity of continued treatment because spontaneous improvement of pseudobulbar affect occurs in some patients.

Minimum Age

Minimum age18 years of age and older

Applies toMembers requesting Nuedexta coverage

Requirement typeAge restriction

For Illinois Marketplace members, approval for a recurring treatment or maintenance medication remains valid for the lesser of 12 months from approval or the length of treatment determined by the treating health professional.
Submit a reauthorization request with the required continuation documentation before the current authorization expires.

Billing Rule

Illinois Approval Duration

For Illinois Marketplace members, prior authorization for Nuedexta as a recurring treatment or maintenance medication for a chronic or long-term condition may not exceed the lesser of 12 months from the date approval is received or the length of treatment determined by the patient's health care professional.

This state-specific duration rule does not expand benefits or require coverage of services otherwise excluded under the member's policy.

Documentation Required

Supporting Medical Records

The plan may require additional documentation, including patient records, test results, and ordering-provider credentials, to determine medical necessity and confirm that treatment is not investigational or experimental.

Submit records sufficient to support the diagnosis, requested therapy, medical necessity, and use within the member's covered benefit.
Additional information may be requested case by case, including member-specific dosing data when dosing is based on weight, body surface area, or another member-specific measurement.
Incomplete or unsupported documentation may result in denial, reimbursement recovery, or other action, including when records indicate inappropriate or excessive billing practices.

Documentation Required

Initial Clinical Documentation

For the initial request, document PBA secondary to a neurological condition and describe the characteristic episodes supporting the diagnosis.

Identify the underlying neurological condition, such as ALS, MS, stroke, or traumatic brain injury.
Document involuntary, sudden, and frequent episodes of laughing and/or crying that are typically out of proportion or incongruent to the underlying emotional state.
Submit the baseline CNS-LS assessment and score of at least 13.

Documentation Required

Contraindication Review

The prescriber must attest, or the clinical reviewer must determine, that the member has no FDA-labeled contraindication that remains unaddressed by the submitted clinical documentation.

Address any applicable contraindication in the request and document the clinical rationale or mitigation when relevant.

Documentation Required

Continuation Documentation

Continuation authorization requires documentation that treatment remains appropriate and beneficial.

Adherence is at least 85% by prescriber verification or medication fill history, or lower adherence is explained by surgery or infection requiring temporary discontinuation.
The prescriber attests, or the clinical reviewer finds, no intolerable adverse effects or drug toxicity.
Document positive clinical response, demonstrated by low disease activity and/or improvement in signs and symptoms.
Document periodic reassessment of the medical necessity for continued treatment because spontaneous improvement of PBA can occur.

Documentation Required

Specialist Consultation Notes

When Nuedexta is prescribed in consultation with a neurologist or psychiatrist, submit the consultation notes with both the initial request and each reauthorization request.

The prescription must be issued by, or made in consultation with, a neurologist or psychiatrist.

Documentation Required

CNS-LS Evaluation

Use the CNS-LS to assess emotional lability symptoms during the past week and submit the completed evaluation with the initial request when required.

The evaluation contains seven assessment questions addressing inappropriate or poorly controlled crying and laughter.
Each item is scored from 1 (applies never) through 3 (applies most of the time).
Calculate and document the total CNS-LS score; the initial coverage threshold is at least 13.

Denial Risk

Clinical Eligibility or Contraindication Not Satisfied

The request may be denied when the member does not meet the covered clinical eligibility requirements or when a required contraindication review is incomplete or unfavorable.

Deny when PBA secondary to a qualifying neurological condition is not documented.
Deny when the characteristic involuntary laughing and/or crying episodes are not documented.
Deny when the baseline CNS-LS score is missing or less than 13.
Deny when an FDA-labeled contraindication is present and has not been addressed in the submitted documentation.

Denial Risk

Continuation Criteria Not Met

Continuation authorization may be denied when required adherence, safety, response, or reassessment criteria are not met.

Adherence is below 85% without the permitted temporary interruption for surgery or infection.
Intolerable adverse effects or drug toxicity are present or cannot be ruled out.
Positive clinical response is not documented.
Periodic reassessment does not support the medical necessity of continued treatment.

Denial Risk

Age or Prescriber Requirement Not Met

The request may be denied if the member is younger than 18 or if the prescription does not meet the qualified-prescriber requirement.

Member must be 18 years of age or older.
The drug must be prescribed by, or in consultation with, a neurologist or psychiatrist.
When consultation is used, submit the consultation notes with the initial request and reauthorization requests.

Denial Risk

Non-PBA Use

Uses of Nuedexta other than treatment of pseudobulbar affect are considered experimental or investigational and may be denied under the applicable off-label policy.

Covered use requires documented PBA secondary to a neurological condition.

Denial Risk

Contraindicated Therapy

Deny or discontinue therapy when a listed contraindication is present, including prohibited concomitant therapy or relevant hypersensitivity, cardiac, or conduction-risk conditions.

Concomitant use with quinidine, quinine, or mefloquine.
History of quinidine-, quinine-, or mefloquine-induced thrombocytopenia, hepatitis, or other hypersensitivity reaction; or known hypersensitivity to dextromethorphan.
Use with a monoamine oxidase inhibitor (MAOI) or within 14 days after stopping an MAOI.
Prolonged QT interval, congenital long-QT syndrome, history suggestive of torsades de pointes, or heart failure.
Complete atrioventricular (AV) block without an implanted pacemaker, or high risk of complete AV block.
Concomitant use with drugs that both prolong the QT interval and are metabolized by CYP2D6, such as thioridazine or pimozide.

At least 13 for initial coverage

Pseudobulbar Affect (PBA)

ConditionPseudobulbar affect (PBA), a specific neurologic condition

SymptomsInvoluntary, sudden, and frequent episodes of laughing or crying

Distinguishing featureEpisodes are out of proportion to or incongruent with the underlying emotional state

Initial Therapy for Pseudobulbar Affect

Nuedexta is indicated for the treatment of pseudobulbar affect.

FDA-approved indication: The patient has pseudobulbar affect (PBA).

PBA involves involuntary, sudden, and frequent episodes of laughing and/or crying that typically occur out of proportion or incongruent to the underlying emotional state. It is distinct from other types of emotional lability associated with neurological disease or injury.

Periodic reassessment: Documentation shows periodic reassessment of the medical necessity of continued treatment because spontaneous improvement of pseudobulbar affect occurs in some patients.