Does J2326 require prior authorization?

No, J2326 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for J2326?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`J2326`, Injection, nusinersen, 0.1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Laboratory values describing the type of mutation or deletion of genes in chromosome 5q (documentation of SMN1 mutation/deletion or compound heterozygous mutation).
Documentation that the member is not dependent on invasive ventilation or noninvasive ventilation beyond use for naps and nighttime sleep.

Key Coverage Criteria

Treatment of spinal muscular atrophy (SMA) in patients who meet ALL of the following criteria: diagnosis of SMA by, or in consultation with, a neurologist with expertise in the diagnosis of SMA; AND submission of medical records confirming mutation or deletion of genes in chromosome 5q resulting in one of the following: homozygous gene deletion or mutation (e.g., homozygous deletion of exon 7 at locus 5q13); OR compound heterozygous mutation (e.g., deletion of SMN1 exon 7 (allele 1) and mutation [...]
Initial therapy: same as above (diagnosis by/with neurologist experienced in SMA; documented 5q SMN1 mutation/deletion), patient is NOT dependent on invasive ventilation OR on non-invasive ventilation beyond use for naps and nighttime sleep, submission of baseline motor exam (HINE-2, HFMSE, RULM, or CHOP INTEND) except baseline assessments for patients < 2 months of age are not necessary, Spinraza prescribed by/with a neurologist experienced in SMA, patient either has not previously received gen [...]
Continuation therapy: diagnosis by, or in consultation with, a neurologist with expertise in the diagnosis of SMA; patient has previously received Spinraza therapy; patient is NOT dependent on invasive ventilation OR on non-invasive ventilation beyond use for naps and nighttime sleep; patient is NOT receiving concomitant chronic SMN modifying therapy (e.g., risdiplam/Evrysdi); submission of medical records with most recent results documenting a positive clinical response from pretreatment baseli [...]
Spinraza is to be administered intrathecally by, or under the direction of, healthcare professionals experienced in performing lumbar punctures, and dosing must be in accordance with FDA-approved labeling.
Medically necessary for initial treatment when: (1) SMA with bi-allelic SMN1 mutations (deletion of both SMN1 or pathogenic variants in both copies, or pathogenic variant in one copy with deletion of the second copy); (2) symptomatic with 2-4 SMN2 copies or asymptomatic with 2-3 SMN2 copies; and (3) not on permanent ventilator dependence.
Medically necessary nusinersen for initial treatment when (1) SMA confirmed by bi-allelic SMN1 mutations (deletion of both SMN1 or pathogenic variants in both copies or compound heterozygous with one deletion), (2) SMN2 copy number criteria met (symptomatic: 2-4 copies; asymptomatic: 2-3 copies), and (3) not permanently ventilator dependent.

7 Active Policies

UHC-POL-spinraza-nusinersen, Spinraza (Nusinersen)

BCBSIL-RX501.086, Nusinersen

BCBSMT-RX501.086, Nusinersen

BCBSNM-RX501.086, Nusinersen

BCBSOK-RX501.086, Nusinersen

UMR-POL-UMR-spinraza-nusinersen, Spinraza (Nusinersen)

SUREST-POL-SUREST-spinraza-nusinersen, Spinraza (Nusinersen)

`J2326`, Injection, nusinersen, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

J2326, Injection, nusinersen, 0.1 mg

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

7 Active Policies

Related Codes

Have a follow-up question?

`J2326`, Injection, nusinersen, 0.1 mg