CurrentUnitedHealthcarePolicy N/A

Spinraza (nusinersen) prior authorization form

This document is a prior authorization request form for Spinraza (nusinersen) used to initiate or continue therapy, to be completed by providers and submitted to UnitedHealthcare/Medicaid.

Policy Summary

PayerUnitedHealthcare

PolicySpinraza (nusinersen) prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form in full and fax it with required documentation to 1-866-940-7328.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8 monthsmaximum length of approval noted on form

5 yearsprovider must retain documentation

1-866-940-7328fax number to submit form

1-800-310-6826Pharmacy PA Call Center phone

Coverage Criteria and Authorization

Authorization submission criteria

Coverage consideration is based on a completed prior authorization form with required documentation and indication of initiation or continuation of therapy.

Submission requirements: Form completed in full

An incomplete form may be returned or lead to denial; maximum approval length noted as 8 months.

Documentation: Official genetic testing confirming diagnosis submitted AND official lab reports (platelet count, coagulation testing, quantitative spot urine) AND motor milestone assessment (name and date) AND copies of recent chart notes and diagnostic evaluations

Provider must retain documentation for five years and fax completed form and records to 1-866-940-7328.

Therapy status indicated: Provider indicates whether request is for initiation of therapy OR continuation of therapy

Policy Summary

PayerUnitedHealthcare

PolicySpinraza (nusinersen) prior authorization form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete the prior authorization form in full and fax it with required documentation to 1-866-940-7328.

SourceLink

On This Page

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Provider Submission Requirements & Actions

Prior Authorization

Prior Authorization Required

Prior authorization required — Prior authorization form must be completed in full and faxed to 1-866-940-7328. The form indicates whether this request is for initiation or continuation of therapy and must include all requested fields (recipient name/ID, prescriber name/NPI, diagnosis, medication, quantity, directions, and prescriber signature).

Fax completed form to 1-866-940-7328
Pharmacy PA Call Center: 1-800-310-6826

Note

Important Provider Action

Important provider action — The prior authorization form must be completed in full; incomplete forms may be returned and will delay review.

Documentation Required

Required Documentation

Required documentation — Official genetic testing and lab reports must be submitted with the prior authorization request. Include documentation such as platelet count, coagulation testing, quantitative spot urine testing, assessment scores (motor milestone assessment name and date), diagnostic evaluations, recent chart notes, and any other supporting medical records. The provider must retain copies of all documentation for five years.

Official genetic testing confirming diagnosis (include date of test)
Platelet count with date
Coagulation laboratory testing with date
Quantitative spot urine testing with date
Assessment name, score and date (motor milestone assessment)
Related chart notes and diagnostic evaluations

Denial Risk

Incomplete Submission Risk

Incomplete submission risk — An incomplete form or missing required documentation (labs, genetic test, assessments, chart notes) may result in referral denial or a request for additional information and will delay authorization. Ensure all fields on the form are filled and all requested official lab reports and testing are attached before faxing.

Background Information

The medical history section captures clinical details relevant to nusinersen therapy, including invasive ventilation status (≤ 16 hours per day), presence of scoliosis, history of spine surgery, and tracheostomy. It also documents use of non‑invasive ventilation for at least 12 hours per day. The form requests confirmation of official genetic testing confirming diagnosis, an Assessment Motor Milestone Score with name and date of the assessment, and recent laboratory results (platelet count, coagulation testing, quantitative spot urine) to support the clinical review.

Definitions and Assessment Fields

inv-12: Official Genetic Testing Confirming Diagnosis

DefinitionOfficial Genetic Testing Confirming Diagnosis: a documented genetic test result confirming the diagnosis

Form requirementCheckbox for confirmation (Yes/No) and a field to record Date of Test are requested on the form

Submission noteOfficial lab reports and testing must be submitted with the prior authorization request

inv-13: Assessment Motor Milestone Score

DefinitionAssessment Motor Milestone Score: documented motor assessment required to support the request

Form requirementCheckbox for whether assessment is provided (Yes/No), plus fields for Name of Assessment and Date of Assessment

Submission noteAssessment and related documentation must be submitted; provider must retain records for five years

OpenPayer

Spinraza (nusinersen) prior authorization form

Coverage Criteria and Authorization

Medication and Coding Details

Provider Submission Requirements & Actions

Background Information

Definitions and Assessment Fields