MMP391.16 update: Neurology biomarker evidence added — preliminary, not validated

UnitedHealthcare updated MMP391.16 (Pharmacogenomics Testing) on March 1, 2026 to add a review of biomarker evidence in neurology (MDC 01), emphasizing preliminary associations rather than clinically validated tests. Recent studies (2020–2024) report lower serum vitamin B12 in chronic migraine, altered intermediary metabolites across chronic pain conditions, and inflammatory/kynurenine pathway signals in diabetic neuropathic pain, but all suffer from small samples, heterogeneous methods, and limited validation. Systematic reviews cited note inconsistent findings for nutraceuticals (including B12, vitamin D, acetyl‑L‑carnitine, alpha‑lipoic acid) and conclude supplements are not standard management for chronic pain. The policy frames these biomarker and metabolomic signals as hypothesis‑generating and calls for larger, standardized studies before influencing coverage or clinical decision‑making.

CAR T Neurologic Toxicity Guidance: Facility Certification, ICANS/CRS Updates

Effective March 11, 2026, UnitedHealthcare clarifies facility expectations and safety details for CAR T–cell therapies in neurologic care: centers offering listed products should be FACT-IEC certified or actively pursuing accreditation. The update highlights rates, timing (commonly 7–12 days), and severity of ICANS and CRS across specific CAR T products and notes the FDA removed the PCNSL limitation for axicabtagene ciloleucel in Feb 2026. Management guidance reiterates supportive care with IL‑6 antagonists (e.g., tocilizumab), corticosteroids, and adjunct agents as used in trials, with ICU-level care required for a subset. Product-specific eligibility, exclusion criteria (including CNS involvement, prior CAR T, active GVHD) and prescribed lymphodepletion regimens are retained to guide risk stratification and institutional preparedness.

Cigna: Cladribine (Mavenclad) Coverage Limited to Relapsing MS; 1‑Year Approvals

Cigna clarifies coverage for cladribine (Mavenclad® and generics) for adults with relapsing forms of MS, aligning use with FDA safety limits and recommending it mainly for patients who failed or cannot tolerate alternative DMTs. Initial and continuing approvals are time‑limited to 1 year and require prescriber documentation of prior therapy failure or high‑activity disease for initiation, and objective evidence of benefit or stabilization for continuation. Treatment must be prescribed by or in consultation with a neurologist or MS specialist. Use is not covered for clinically isolated syndrome, non‑relapsing MS phenotypes (e.g., primary progressive MS), or in combination with other MS DMTs.

UnitedHealthcare: Spinal MUA/SMUA Classified Unproven & Not Medically Necessary

Effective March 1, 2026, UnitedHealthcare now classifies manipulation under anesthesia (MUA), including spinal manipulation under anesthesia (SMUA) and medication-assisted spinal manipulation (MASM), as unproven and not medically necessary when performed for spine indications. The policy cites consistently low-quality evidence—small, nonrandomized studies, short follow-up, and methodological bias—and professional guidance from ACOEM opposing MUA/MASM for acute, subacute, or chronic low back and cervicothoracic pain. MUA is defined broadly to include procedures performed with general anesthesia, sedation, or local anesthetic by various practitioners, but the proposed mechanism of breaking adhesions is not proven safe or effective. Providers should not expect coverage for spinal MUA/MASM except where explicitly supported elsewhere in the policy.

Adalimumab: Neurosarcoidosis Added with Prior-therapy and 1‑yr Continuation Criteria

Cigna updated its IP0652 policy (effective 2026-03-15) to add neurosarcoidosis guidance under “Other Uses with Supportive Evidence,” citing the 2021 European Respiratory Society recommendation that a TNF inhibitor may be used after trials of glucocorticoids and immunosuppressants. Adalimumab products are eligible under this supportive-evidence pathway but require prior therapy with at least one immunosuppressant (examples: methotrexate, azathioprine, mycophenolate, cyclophosphamide, or infliximab) before approval. Patients already on adalimumab can receive a one-year continuation if they’ve been on therapy ≥3 months, show objective improvement on at least one measure relevant to the organ system, and have symptomatic improvement from baseline. Prescribing should be by or in consultation with an appropriate specialist (e.g., pulmonologist, ophthalmologist, dermatologist) and documentation of objective benefit is required for continued authorization.

Cigna: Evrysdi (SMA) Coverage Updated — 4‑month starts, 1‑yr renewals

Cigna revised its SMA coverage policy to rename Risdiplam to Spinal Muscular Atrophy - Evrysdi and add Evrysdi oral tablets with updated documentation and authorization timelines. Initial approvals now require documented genetic confirmation (bi‑allelic pathogenic SMN1 variants), specified SMN2 copy-number criteria, a baseline motor assessment with validated scales, verification of no prior Zolgensma or Itvisma, and are granted for 4 months. Ongoing therapy approvals require the same genetic/SMN2 criteria, specialist involvement, and documented clinical improvement or stabilization and are authorized for 1 year. Evrysdi is not considered medically necessary for patients with complete limb paralysis or permanent ventilator dependence, nor for concurrent use with Spinraza. The policy references FIREFISH, SUNFISH, and RAINBOWFISH trials and aligns SMN2-based treatment pathways with guideline evidence.

Spinal Fusion, Decompression & Vertebral Body Tethering Revised — Apr 1, 2026

UnitedHealthcare revised its policies for spinal fusion and decompression and for vertebral body tethering for scoliosis, with both revisions effective April 1, 2026. The March–April 2026 bulletin lists these as revised entries under MDC 01 (Neurology & Nervous System) but does not include the revised clinical criteria, coding lists, or documentation requirements in the summary notice. Providers should treat this as notice that formal policy language has changed and refer to the full UnitedHealthcare policy documents for updated indications, age/curve criteria, coding, and prior authorization requirements. These spine updates are part of a broader March–April 2026 policy maintenance cycle across multiple service lines.

Premera: Request for Feedback on Neurology/Spine Policies — Mar 5, 2026

Premera Blue Cross is soliciting stakeholder feedback by March 5, 2026 on a broad set of medical policies, including several MDC 01 Neurology & Nervous System items (Deep Brain Stimulation 7.01.63; Ablative Treatments for Occipital Neuralgia, Chronic Headaches, and Atypical Facial Pain 7.01.563; Pulsed Radiofrequency for Chronic Pain 7.01.564; Artificial Intervertebral Disc: Lumbar Spine 7.01.589). The notice lists policy numbers and titles but does not include draft language, proposed coverage criteria, coding changes, or rationale for revisions. This publication functions solely as a request for feedback on the enumerated policies within a larger multidisciplinary review list. Providers should note the March 5, 2026 deadline if they wish to submit input on these neurology/spine and pain management policies.

Cigna (0158) Updates: Device‑Specific Hypoglossal Nerve Stimulator Criteria, DISE & Pediatric Down Syndrome

Effective 6/15/2026 Cigna updated coverage for FDA‑approved implantable hypoglossal nerve stimulation devices for OSA to include device‑specific medical necessity criteria, explicit DISE requirements, and pediatric Down syndrome indications. Inspire and Genio® System 2.1 have separate age, AHI and BMI thresholds (Inspire adults ≥18: AHI 15–100, BMI ≤40; Genio® ≥22: AHI 15–65, BMI ≤32; Inspire adolescents 13–18 with Down syndrome: AHI >10–<50, BMI ≤95th percentile). Coverage requires documented PAP failure/intolerance (or unwillingness), central+mixed apneas ≤25% of AHI, absence of complete concentric collapse on DISE, and adherence to FDA PMA conditions. Remote replacement of malfunctioning, out‑of‑warranty remotes is covered, while off‑the‑shelf remote batteries are generally not medically necessary; related DISE and implantation CPT codes are listed.

Cigna EN0383: TMS Coverage Update — Evidence, FDA Device Context, Limits

Cigna updated its Transcranial Magnetic Stimulation (TMS) coverage policy (EN0383) effective March 15, 2026, consolidating FDA device clearances and an expanded evidence review across multiple TMS modalities (rTMS, dTMS, iTBS/TBS, accelerated/SAINT, priming, and navigated TMS). The policy affirms coverage scope for certain indications—notably treatment‑resistant major depressive disorder and OCD per device labeling—while enumerating many psychiatric, neurologic, addiction, and pediatric uses as not established or investigational due to limited or inconsistent evidence. Key rationale reflects heterogeneity in study designs, small sample sizes, short follow‑up, variable stimulation parameters, and device‑specific safety signals (headache, rare seizures), and it cites device FDA 510(k) contexts when informing coverage. Navigated TMS has FDA clearance for motor mapping but evidence for improved long‑term surgical outcomes remains limited and nonrandomized, so many novel/accelerated protocols are considered investigational pending stronger, durable, multisite data.