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    v1.0.28
    OpenPayerPolicy UpdatesPulmonologyNeighborhood Health Plan RI Brinsupri Coverage | O…
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    CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

    Brinsupri for non-cystic fibrosis bronchiectasis — Coverage Criteria

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    Covers medical necessity criteria, authorization, and quantity limits for Brinsupri (adult and pediatric ≥12 years) to treat non-cystic fibrosis bronchiectasis for Neighborhood Health Plan of Rhode Island Medicaid members.

    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyBrinsupri for non-cystic fibrosis bronchiectasis — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 2026
    Last ReviewNov 1, 2025
    Next Review DateNov 1, 2025
    Key ActionObtain prior authorization documenting HRCT-confirmed bronchiectasis, pulmonologist involvement, exclusion of cystic fibrosis, nonsmoker status, and required exacerbation history.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    12 monthsauthorization length
    ≥12 yrsminimum age

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1 tab/day
    quantity limit
    ≥2adult exacerbation threshold
    ≥1adolescent exacerbation threshold

    Coverage Criteria for Brinsupri (NCFB)

    Initial Therapy

    Authorization of 12 months may be granted when ALL of the following are met:

    Initial authorization criteria: A. Member is 12 years of age or older.
    Prescriber: B. Brinsupri is prescribed by or in consultation with a pulmonologist.
    Diagnostic confirmation: C. Documentation that the diagnosis is confirmed by a high-resolution computed tomography (HRCT) study of the chest and clinical history consistent with bronchiectasis (e.g., chronic cough, chronic sputum production, and/or recurrent respiratory tract infections).
    Etiology and smoking status: D. Physician attestation that the member does not have bronchiectasis due to cystic fibrosis, bronchiectasis is not primarily caused by a comorbid diagnosis of COPD or asthma, and the member is a current nonsmoker.
    Exacerbation history: E. Documentation of the number of pulmonary exacerbations the member has experienced in the last 12 months. For members aged 18 and older: at least two pulmonary exacerbations in the last 12 months; for members aged 12–17 years: at least one pulmonary exacerbation in the last 12 months.

    Continuation Therapy

    Authorization of 12 months may be granted when ALL of the following are met:

    Positive response: A. Documentation that the member has experienced a positive response to therapy (e.g., reduction in pulmonary exacerbations from baseline).

    Use of Brinsupri for any indication other than the FDA‑approved treatment of non‑cystic fibrosis bronchiectasis (NCFB) is considered experimental/investigational.

    Any non‑FDA‑approved indication for Brinsupri is considered not medically necessary and may be denied.

    Coding and Clinical Thresholds

    Pulmonary exacerbations in prior 12 months — threshold
    Adults (age ≥18)At least 2 pulmonary exacerbations in the prior 12 months.
    Adolescents (ages 12–17)At least 1 pulmonary exacerbation in the prior 12 months.
    Documentation requiredNumber of pulmonary exacerbations in the last 12 months must be documented in the medical record.

    Provider Requirements and Authorization Process

    Prior Authorization

    Initial authorization — document all required elements

    Prior authorization may be approved for a 12-month period when all initial criteria are documented: member is ≥12 years of age; Brinsupri is prescribed by or in consultation with a pulmonologist; diagnosis confirmed by HRCT plus clinical history consistent with bronchiectasis; physician attestation excluding cystic fibrosis and that bronchiectasis is not primarily caused by COPD or asthma and that the member is a current nonsmoker; and documentation of pulmonary exacerbation count in the prior 12 months (adults ≥2; ages 12–17 ≥1).

    • A. Member is 12 years of age or older.
    • B. Brinsupri is prescribed by or in consultation with a pulmonologist.
    • C. HRCT confirmation of diagnosis and clinical history consistent with bronchiectasis (e.g., chronic cough, chronic sputum production, and/or recurrent RTIs).
    • D. Physician attestation that bronchiectasis is not due to CF, not primarily caused by COPD or asthma, and the member is a current nonsmoker.
    • E. Documentation of number of pulmonary exacerbations in last 12 months (adults: ≥2; ages 12–17: ≥1).
    Prior Authorization

    Background

    Brinsupri is FDA‑approved for the treatment of non‑cystic fibrosis bronchiectasis (NCFB) in adult and pediatric patients aged 12 years and older. All other uses are classified as experimental/investigational and not medically necessary.

    Definitions

    Pulmonary exacerbation — definition
    Minimum durationWorsening of symptoms for at least 48 hours.
    Number of symptomsWorsening of three or more of the specified symptoms.
    Symptoms listIncreased cough; increased sputum production or change in sputum consistency; increased sputum purulence; increased breathlessness and/or decreased exercise tolerance; fatigue and/or malaise; or hemoptysis.
    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyBrinsupri for non-cystic fibrosis bronchiectasis — Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 2026
    Last ReviewNov 1, 2025
    Next Review DateNov 1, 2025
    Key ActionObtain prior authorization documenting HRCT-confirmed bronchiectasis, pulmonologist involvement, exclusion of cystic fibrosis, nonsmoker status, and required exacerbation history.
    SourceLink
    On This Page
    Coverage Criteria for Brinsupri (NCFB)Coding and Clinical ThresholdsProvider Requirements and Authorization ProcessBackgroundDefinitions

    Continuation authorization — show clinical benefit

    Continuation authorization may be granted for 12 months when documentation shows a positive response to therapy, for example a reduction in pulmonary exacerbations from baseline.

    • Provide objective documentation that pulmonary exacerbations have decreased compared with baseline.
    Note

    Provider submission — include complete supporting documentation

    Ensure the prior authorization request includes all required supporting documentation and clearly lists the specific elements below to avoid processing delays or denials.

    • Include HRCT report and relevant clinical history.
    • Attach physician attestation regarding CF, COPD/asthma causation, and smoking status.
    • Report exact number of pulmonary exacerbations in the prior 12 months and any evidence of reduction for continuation requests.
    • Confirm prescriber is a pulmonologist or that pulmonology consultation is documented.
    Documentation Required

    Required clinical documentation

    Required clinical documentation must include HRCT confirmation of bronchiectasis, clinical history consistent with bronchiectasis, physician attestation excluding cystic fibrosis and primary COPD/asthma causation, current nonsmoker status, and the number of pulmonary exacerbations in the last 12 months.

    • HRCT chest report confirming bronchiectasis.
    • Clinical history (e.g., chronic cough, chronic sputum production, recurrent RTIs).
    • Physician attestation that bronchiectasis is not due to CF and not primarily caused by COPD or asthma.
    • Statement that the member is a current nonsmoker.
    • Count of pulmonary exacerbations in the prior 12 months with definition of exacerbation as worsening of ≥3 specified symptoms for ≥48 hours.
    Step Therapy

    Prescriber requirement — pulmonologist involvement

    Brinsupri must be prescribed by a pulmonologist or prescribed in consultation with a pulmonologist; include evidence of the prescribing relationship in the request.

    • Order must be from a pulmonologist or include documentation of pulmonology consultation.
    Denial Risk

    Indication restriction — non‑approved uses not covered

    Use of Brinsupri for indications other than the FDA‑approved treatment of non‑cystic fibrosis bronchiectasis is considered experimental/investigational and not medically necessary and may be denied.

    • Do not submit requests for non‑FDA‑approved indications; such requests are subject to denial as not medically necessary.