CommercialPrior AuthHigh impact
Nusinersen (Spinraza) (CPB 0915, reviewed 2026-09-09)
Aetna·Neurology, Pediatrics, Genetics·Medical Policy
We identified it
Oct 4, 2026
Summary
Aetna updated its clinical policy for nusinersen (Spinraza) for spinal muscular atrophy treatment, effective immediately. The policy establishes mandatory precertification requirements, specifies genetic documentation and baseline assessment requirements, defines two dosing regimens (low-dose and high-dose), and clarifies continuation criteria based on demonstrated clinical response. Billing teams must implement prior authorization workflows and ensure claims include required documentation of SMA type, genetic testing, motor assessment scores, and ventilation status.
Action Required
Immediately implement the following: (1) Billing team: Add nusinersen (Spinraza) to the prior authorization requirements list in the billing system. All claims require precertification before administration—direct providers to call (866) 752-7021 or fax (888) 267-3277 for approval. (2) Update claim submission guidelines to require submission of: genetic documentation confirming 5q SMA mutation/deletion, baseline motor assessment scores (HINE-2, HFMSE, or CHOP-INTEND), and ventilation status documentation. (3) For continuation requests: Ensure medical records dated within 1 month prior to request submission include documented clinical response per policy criteria (specific point improvements on motor assessments or achievement of new motor milestones). (4) Coding staff: Ensure CPT 62270 (lumbar spinal puncture) and anesthesia code 00635 are linked to nusinersen claims when applicable. Biomarker testing codes (0361U, 0547U, 86316) are NOT covered for SMA monitoring—deny or reverse claims for these codes when used for therapeutic effectiveness monitoring. (5) Network verification: Confirm nusinersen administration occurs at an Aetna Institutes® GCIT Designated Network facility unless member's plan has elected not to require this. (6) Provider communication: Notify all neurology and pediatric specialists prescribing Spinraza that treatment must be prescribed by or in consultation with an SMA specialist and that concomitant use with Evrysdi (risdiplam) is not permitted. Claims violating this will be denied. Failure to obtain precertification will result in automatic claim denial.