CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dextromethorphan/Quinidine (Nuedexta) for Pseudobulbar Affect (PBA)

This policy governs coverage of Nuedexta (dextromethorphan/quinidine) for treatment of pseudobulbar affect (PBA) for Medicaid members of Neighborhood Health Plan of Rhode Island when approval criteria are met.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDextromethorphan/Quinidine (Nuedexta) for Pseudobulbar Affect (PBA)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 20, 2017

Next Review DateN/A

Key ActionObtain prior authorization showing a diagnosis of pseudobulbar affect (PBA) and required documentation of positive clinical response for renewals.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 moapproval duration

FDA-approvedPBA indication

response requiredcontinuation need

Coverage Criteria for Dextromethorphan/Quinidine (Nuedexta)

Initial Approval Criteria

Covered when ALL of the following are met:

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDextromethorphan/Quinidine (Nuedexta) for Pseudobulbar Affect (PBA)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 20, 2017

Next Review DateN/A

Key ActionObtain prior authorization showing a diagnosis of pseudobulbar affect (PBA) and required documentation of positive clinical response for renewals.

SourceLink

On This Page

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Provider Responsibilities and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required before coverage. Approvals will be issued for up to 12 months for initial and renewal requests and are conditional on documentation requirements and clinical response criteria being met.

Prior authorization required prior to medication initiation
Approval duration: up to 12 months (initial and renewal)

Denial Risk

Non‑FDA Indications Not Covered

Requests for Nuedexta (or dextromethorphan/quinidine) for indications other than the FDA‑approved indication of pseudobulbar affect (PBA) are considered experimental/investigational and are NOT a covered benefit. Do not submit prior authorization requests for non‑FDA indications expecting coverage.

Non‑FDA indications (including emotional lability not meeting PBA criteria) are not covered
PBA is the only covered indication

Documentation Required

Required Clinical Documentation

Submit all applicable clinical documentation with initial and continuation prior authorization requests. Incomplete documentation may delay review or result in denial.

Diagnosis documentation confirming pseudobulbar affect (PBA)
For initial requests: clinical notes describing PBA symptoms and their impact
For continuation/renewal requests: documentation of positive clinical response to therapy (improvement in frequency/severity of PBA episodes)
Medication history including prior therapies and dates
Relevant neurologic diagnosis(es) associated with PBA (e.g., ALS, MS, stroke)

Key Definitions

Pseudobulbar affect (PBA) — definition and clinical characterization

DefinitionA condition occurring secondary to neurologic disease characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are out of proportion or incongruent to the underlying emotional state.

Clinical featuresEpisodes are sudden, frequent, involuntary, and typically disproportionate or incongruent with the patient’s actual emotions.

EtiologyOccurs secondary to a variety of otherwise unrelated neurologic conditions (i.e., a consequence of underlying neurologic disease or injury).

Distinct entityPBA is distinct from other types of emotional lability seen in neurological disease or injury.

Coverage relevanceFDA‑approved indication for Nuedexta (dextromethorphan/quinidine); other indications are experimental/investigational and not covered.

OpenPayer

Dextromethorphan/Quinidine (Nuedexta) for Pseudobulbar Affect (PBA)

Coverage Criteria for Dextromethorphan/Quinidine (Nuedexta)

Provider Responsibilities and Authorization Requirements

Background

Key Definitions