CurrentUnitedHealthcarePolicy N/A

Spinraza (nusinersen) prior authorization form for Medicaid

Prior authorization request form and documentation checklist for initiation or continuation of nusinersen (Spinraza) for Medicaid recipients. Specifies required clinical, laboratory and administrative information to be submitted for review; notes max approval length and retention requirements.

Policy Summary

PayerUnitedHealthcare

PolicySpinraza (nusinersen) prior authorization form for Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must fax the completed form and required official lab reports and testing to 1-866-940-7328 or contact the Pharmacy PA Call Center; incomplete forms may be returned and will delay review.

POLICY UPDATE CHANGES

No material clinical/coverage changes

8 monthsMaximum Approval Length

5 yearsRequired Document Retention

Coverage Summary

This is a prior authorization request form and documentation checklist for initiation or continuation of nusinersen (Spinraza) for Medicaid recipients. It specifies required clinical, laboratory, and administrative information to be submitted for review, notes a maximum approval length of 8 months, and requires providers to retain copies of all documentation for 5 years. Coverage stance: covered_with_criteria; subject: Spinraza (nusinersen) prior authorization form for Medicaid.

Authorization Request & Administrative Criteria

Authorization request elements

Prior authorization will be reviewed when ALL of the following documentation is provided:

Completed request form with recipient's Medicaid ID#, date of birth, recipient full name, prescriber's full name, NPI, phone number and fax number
Medication details: Medication: Spinraza (nusinersen) with specified quantity and directions
Indication and specialty: Indication/Diagnosis and prescriber specialty
Therapy selection: Selection of Initiation of Therapy OR Continuation of Therapy
Medical history items completed: invasive ventilation (<16 hours per day) status, scoliosis, non-invasive ventilation (>=12 hours/day) status, spine surgery, tracheostomy
Genetic testing: Official genetic testing confirming diagnosis
Official lab reports and testing must be submitted with the prior authorization request
Motor milestone assessment: Assessment motor milestone score (name of assessment and date of assessment)
Laboratory testing: platelet count and coagulation laboratory testing with dates
Form and lab data must be completed in full
Urine testing: Quantitative spot urine testing with date
Prescriber signature: Prescriber's signature and date
Supporting records: Copies of medical records, diagnostic evaluations, recent chart notes, and most recent related labs

Administrative requirements

Approval processing constraints and retention:

Maximum approval length: Maximum length of approval is 8 months
Incomplete form return: Form and lab data must be completed in full; incomplete forms may be returned
Provider retention requirement: Provider must retain copies of all documentation for five years

What Providers Must Do

Prior Authorization

Submit completed prior authorization form and supporting documentation

Fax the completed prior authorization form and required official lab reports and testing to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-800-310-6826. Incomplete forms may be returned and will delay review.

Documentation Required

Provide genetic testing and clinical assessment data

Submit official genetic testing confirming the diagnosis; the assessment motor milestone score including the name of the assessment and date of assessment; platelet count and coagulation laboratory testing with dates; and quantitative spot urine testing with date.

Documentation Required

Maintain records

Provider must retain copies of all documentation submitted for this request for five years.

Billing Rule

Approval duration

The maximum length of approval for Spinraza (nusinersen) is 8 months per authorization.

Form-specific Definitions

UnitedHealthcare Medicaid prior authorization form for Spinraza (nusinersen). The form requires completion of recipient and prescriber identification (Medicaid ID#, date of birth, recipient full name, prescriber full name, NPI, phone and fax), medication details (Spinraza, quantity, directions), indication/diagnosis, prescriber specialty, and selection of Initiation of Therapy or Continuation of Therapy.

Required clinical and laboratory data must be submitted with the request, including medical history fields (invasive ventilation <16 hours/day, non-invasive ventilation ≥12 hours/day, scoliosis, spine surgery, tracheostomy), official genetic testing confirming diagnosis, assessment motor milestone score with the name and date of the assessment, platelet count and coagulation laboratory testing with dates, and quantitative spot urine testing with date. Copies of medical records, diagnostic evaluations, recent chart notes, and the most recent related labs are also required.

Administrative submission instructions: the form and lab data must be completed in full (incomplete forms may be returned). Fax the completed form and required official lab reports and testing to 1-866-940-7328 or contact the Pharmacy PA Call Center at 1-800-310-6826. Providers must retain copies of all documentation for five years.

Term	Definition
Invasive ventilation <16 hours per day
Form field asking whether the patient uses invasive ventilation for less than 16 hours per day (Yes/No).
Non-invasive ventilation for at least 12 hours per day
Form field asking whether the patient uses non-invasive ventilation for at least 12 hours per day (Yes/No).