CommercialPrior AuthHigh impact
Nusinersen (Spinraza™)
BCBS Tennessee·TN · Neurology, Pediatrics, Genetics·Medical Policy
Effective date
Dec 1, 2026
We identified it
Sep 10, 2026
Summary
BlueCross BlueShield of Tennessee has issued a new medical policy for Nusinersen (Spinraza™) covering treatment of spinal muscular atrophy (SMA). The policy establishes comprehensive coverage criteria requiring prior authorization, genetic testing confirmation (≤3 SMN2 gene copies), neurologist prescription, baseline laboratory tests, and documented motor/respiratory function. The policy is NOT YET EFFECTIVE and must not be implemented until December 1, 2026.
Action Required
By November 15, 2026: Billing and authorization teams must prepare systems for policy implementation. (1) Update prior authorization workflows in billing software to require: neurologist/SMA specialist consultation documentation, genetic testing confirmation (SMN2 gene copy number ≤3), baseline laboratory tests (platelet count, prothrombin time, activated partial thromboplastin time, quantitative spot urine protein), motor function assessment using validated scales (HINE, HFMSE, CHOP INTEND, BSID-III, 6MWT, ULM, MFM32, RULM), respiratory function tests (FVC), and documentation excluding advanced disease/complete limb paralysis/permanent ventilation. (2) Create prior authorization checklist verifying patient meets all coverage criteria including SMA phenotype I/II/III diagnosis, SMN1 gene testing results, and no prior SMA gene therapy (Zolgensma/Itvisma) or case-by-case review documentation if previously treated. (3) Configure system to flag claims for J2326 as requiring prior auth under this policy effective 12/1/26. (4) Train authorization team on continuation therapy criteria requiring documented response to treatment (motor/respiratory stability/improvement or reduced respiratory infections). (5) Update provider communications and templates to collect required baseline and pre-administration laboratory tests. Failure to implement prior authorization requirements will result in claim denials after the effective date.