CommercialPrior AuthHigh impact
Nusinersen (Spinraza) (CPB 0915, reviewed 2026-07-31)
Aetna·Neurology, Pediatrics, Genetics·Medical Policy
Effective date
Jul 31, 2026
We identified it
Aug 18, 2026
Summary
Aetna updated its Spinraza (nusinersen) policy for spinal muscular atrophy, effective July 31, 2026. The policy establishes clear precertification requirements, defines eligibility criteria for initial approval and continuation of therapy, specifies two dosing regimens (low-dose and high-dose), and designates administration locations through Aetna Institutes GCIT Network. Billing teams must implement prior authorization workflows and ensure claims include required baseline motor assessments (HINE-2, HFMSE, or CHOP-INTEND).
Action Required
Before July 31, 2026: (1) Billing team must establish precertification requirement for all Spinraza claims—update billing system to trigger mandatory prior auth requests to Aetna at (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity forms. (2) Providers must document baseline motor assessment (HINE-2, HFMSE, or CHOP-INTEND) prior to therapy initiation; add requirement to EMR and claim submission checklist. (3) Ensure claims capture genetic documentation of 5q SMA mutation and ventilation status; add data fields to encounter forms. (4) Front desk and prior auth staff must verify patient is not receiving Spinraza and Evrysdi concomitantly and confirm administration will occur at Aetna Institutes GCIT-designated network location. (5) Code CPT 62270 (lumbar puncture) and 00635 (anesthesia for lumbar procedures) appropriately with claim submissions. Do NOT bill experimental biomarker codes (0361U, 0547U, 86316 when used for monitoring SMA response). Failure to obtain precertification will result in claim denial; missing baseline assessments will delay or deny authorization.