CurrentNeighborhood Health Plan of Rhode IslandPolicy Nuedexta PA Policy 870-A, 599-A UDR 04-2024

Nuedexta (dextromethorphan/quinidine) prior authorization

This document sets prior authorization requirements for Nuedexta for treatment of pseudobulbar affect (PBA) for members of Neighborhood Health Plan of Rhode Island managed through CVS Caremark criteria. It governs initial and continuation authorization and duration of approvals.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNuedexta (dextromethorphan/quinidine) prior authorization

Policy CodePolicy Nuedexta PA Policy 870-A, 599-A UDR 04-2024

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document a diagnosis of pseudobulbar affect (PBA); for continuation requests show decreased or maintained reduction in PBA episodes since starting therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FDA-approved for PBAIndication

PBA diagnosis requiredPrimary requirement

4 monthsInitial approval

12–36 moContinuation approval

Coverage and Authorization Criteria

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Authorization criteria

Covered when ALL of the following are met:

Primary diagnosis: The patient has a diagnosis of pseudobulbar affect (PBA).

Request type

Not continuation: The request is NOT for continuation of therapy.
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Continuation: The request is for continuation of therapy.
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Benefit on continuation: For continuation requests, the patient has achieved or maintained a decrease in pseudobulbar affect (PBA) episodes since starting the requested drug.

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This policy does not cover requests that are explicitly not for continuation when continuation-specific criteria are required. If a request is submitted that indicates it is not a continuation of therapy but the clinical rules or requested pathway require continuation documentation or evidence, the request will be processed as non-covered under those continuation provisions.

Provider Requirements and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Nuedexta (dextromethorphan hydrobromide/quinidine sulfate) for the treatment of pseudobulbar affect (PBA). Coverage is allowed when documentation supports a diagnosis of PBA — characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are disproportionate or incongruent to the patient’s underlying emotional state.

Prior authorization required for Nuedexta (dextromethorphan hydrobromide/quinidine sulfate).
Coverage allowed only for a documented diagnosis of pseudobulbar affect (PBA).
Requests without a diagnosis of PBA will be denied.
For continuation requests, documentation must show the patient has achieved or maintained a decrease in PBA episodes since starting Nuedexta.

Documentation Required

Clinical Documentation Required

Document the diagnosis and clinical features of pseudobulbar affect (PBA). Clinical documentation should describe involuntary, sudden, and frequent episodes of laughing and/or crying that are out of proportion to or incongruent with the patient’s emotional state, and note the neurologic condition associated with PBA.

Include the PBA diagnosis and supporting clinical description in the medical record.
State the associated neurologic condition (e.g., ALS, MS, stroke, traumatic brain injury) contributing to PBA.

Denial Risk

Diagnosis Requirement — Denial Risk

Requests for Nuedexta will be denied if the patient does not have a documented diagnosis of pseudobulbar affect (PBA).

Ensure the submitted documentation clearly indicates PBA; non‑specific emotional lability without PBA criteria is not sufficient for approval.

Note

Provider Action — Continuation Therapy

For continuation of therapy, include objective documentation that the patient has achieved or maintained a decrease in PBA episode frequency or severity since initiating Nuedexta. If continuation criteria are not met, the request may be denied.

Indicate duration of therapy and clinical response (e.g., reduction in episode frequency/severity).
If requesting continuation, explicitly state prior authorization is for continuation and provide evidence of benefit.

Background and Clinical Context

Pseudobulbar affect (PBA) is a syndrome secondary to various neurologic conditions, characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are disproportionate or incongruent with the underlying emotional state. Nuedexta (dextromethorphan/quinidine) is FDA‑approved for treatment of PBA, and this policy establishes prior authorization requirements for its use, including criteria for both initial and continuation therapy.

Definitions

Pseudobulbar affect (PBA) definition — A condition secondary to neurologic disease characterized by involuntary, sudden, and frequent episodes of laughing and/or crying, typically…

DefinitionA condition secondary to neurologic disease characterized by involuntary, sudden, and frequent episodes of laughing and/or crying

Typical clinical featureEpisodes are typically out of proportion or incongruent to the underlying emotional state

EtiologyOccurs secondary to a variety of otherwise unrelated neurologic conditions

DistinctnessPBA is distinct from other types of emotional lability seen in neurological disease or injury