CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Dextromethorphan/quinidine (Nuedexta) — Coverage Criteria for Pseudobulbar Affect

Covers authorization criteria and duration of approval for Nuedexta (dextromethorphan/quinidine) to treat pseudobulbar affect (PBA) for Neighborhood Health Plan of Rhode Island members.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDextromethorphan/quinidine (Nuedexta) — Coverage Criteria for Pseudobulbar Affect

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization documenting a PBA diagnosis and evidence of decreased PBA episodes since initiation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

PBA indicationFDA-approved indication described

Initial DOA: 4 monthsInitial therapy duration(s) listed

Continuation DOA: 12–36 monthsContinuation therapy durations listed (by reference)

870-A, 599-AInternal reference numbers

Coverage and Medical Necessity Criteria

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Provider Requirements and Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization required for Nuedexta for treatment of pseudobulbar affect (PBA). Approval is contingent on a documented PBA diagnosis and evidence of clinical response (see documentation requirements).

Affected drug: Nuedexta (dextromethorphan hydrobromide/quinidine sulfate)

Step Therapy

No step therapy sequencing or requirement to try alternative agents is specified for Nuedexta in this policy.

Documentation Required

Required Documentation

Documentation must confirm the diagnosis of pseudobulbar affect (PBA) and include clinical evidence that the patient has achieved or maintained a decrease in PBA episodes since initiation of the requested drug. Include relevant clinical notes, baseline and follow-up episode frequency, and any supporting neurological diagnoses or assessments.

Confirm PBA diagnosis
Document decrease in PBA episodes since starting therapy
Provide clinical notes and baseline/follow-up episode frequency

Denial Risk

Denial Triggers

Authorization may be denied if there is no documented diagnosis of PBA or if documentation does not show a demonstrated clinical response (no decrease in PBA episodes) since treatment initiation.

Denial triggers: absent PBA diagnosis; lack of documented clinical response

Clinical Background

Pseudobulbar affect (PBA) is a disorder encountered in patients with underlying neurologic disease or injury and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are disproportionate or incongruent to the patient's underlying emotional state. Nuedexta (dextromethorphan/quinidine) is indicated for the treatment of PBA; authorization is contingent on a documented PBA diagnosis and evidence of a clinical response, specifically a decrease in PBA episodes after initiation of therapy.

Key Definitions

Pseudobulbar affect (PBA) — definition and relation to neurologic disease/injury

DefinitionA condition secondary to neurologic disease or injury characterized by involuntary, sudden, and frequent episodes of laughing and/or crying that are typically disproportionate or incongruent to the patient’s underlying emotional state.

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

Clinical featuresEpisodes are involuntary, sudden, frequent, and often out of proportion or incongruent with the patient’s actual emotions.

DistinctnessPBA is a specific condition distinct from other types of emotional lability seen in neurologic disease or injury.

FDA‑approved treatment contextNuedexta (dextromethorphan/quinidine) is indicated for the treatment of PBA.