By Counterforce Health Team in Evrysdi (risdiplam) —

How to Get Evrysdi (Risdiplam) Covered by UnitedHealthcare in New Jersey: Prior Authorization, Appeals, and Coding Guide

Answer Box: Getting Evrysdi Covered by UnitedHealthcare in New Jersey

UnitedHealthcare requires prior authorization for Evrysdi (risdiplam) in New Jersey with specific documentation: genetic confirmation of 5q-linked SMA, baseline motor function scores, and neurologist consultation. If denied, you have 180 days to appeal internally, then 60 days for New Jersey's IHCAP external review. Start today by gathering genetic test results, recent weight documentation, and motor assessments. Submit through the UnitedHealthcare provider portal or call member services for PA forms.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for SMA
  3. Product Coding: HCPCS, J-Codes, and NDCs
  4. Clean Prior Authorization Anatomy
  5. Frequent Coding and Billing Pitfalls
  6. Verification with UnitedHealthcare Resources
  7. Appeals Process in New Jersey
  8. Quick Pre-Submission Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Evrysdi (risdiplam) is typically covered under the pharmacy benefit since it's an oral, self-administered medication. However, understanding both pathways helps ensure proper billing and reduces denials.

Pharmacy Benefit Path (Most Common)

  • Uses NDC codes for billing
  • Requires prior authorization through OptumRx
  • Dispensed via Optum Specialty Pharmacy
  • Patient responsibility based on formulary tier

Medical Benefit Path (Limited Cases)

  • Uses HCPCS J8499 ("Prescription drug, oral, non-chemotherapeutic, not otherwise specified")
  • May apply for certain Medicaid programs or specific plan designs
  • Requires detailed documentation and medical necessity justification
Tip: Verify benefit design with UnitedHealthcare before submission. Self-funded employer plans may have different coverage pathways than fully-insured plans.

ICD-10 Mapping for SMA

Accurate ICD-10 coding is crucial for Evrysdi approval. Use the most specific code supported by your documentation.

Primary ICD-10 Codes for SMA

ICD-10 Code Description Documentation Requirements
G12.0 Infantile spinal muscular atrophy, type I Genetic confirmation, early onset symptoms, Werdnig-Hoffmann features
G12.1 Other inherited spinal muscular atrophy Genetic confirmation, later onset, types II-IV
G12.9 Spinal muscular atrophy, unspecified Only when genetic results pending—avoid as default

Documentation Words That Support Coding

  • "Homozygous deletion of SMN1 exon 7"
  • "SMN2 copy number: [X] copies"
  • "Genetic counseling completed"
  • "Progressive muscle weakness"
  • "Lower motor neuron signs"
  • "Baseline motor assessment completed"
Note: Never use G12.9 (unspecified) without clear justification. Payers flag this code for additional review, increasing denial risk.

Product Coding: HCPCS, J-Codes, and NDCs

NDC Codes for Evrysdi

  • NDC 50242-175-07: 60 mg/80 mL oral solution (most common)
  • NDC 50242-215-01: 5 mg tablets (for patients ≥20 kg)

HCPCS Coding

  • J8499: For medical benefit billing
  • Include detailed description: "Evrysdi (risdiplam) oral solution"

Units and Dosing Math

Evrysdi dosing is weight and age-based:

Patient Category Dose Volume Calculation
<2 months 0.15 mg/kg daily (Weight × 0.15) ÷ 0.75 mg/mL
2 months to <2 years 0.20 mg/kg daily (Weight × 0.20) ÷ 0.75 mg/mL
≥2 years, <20 kg 0.25 mg/kg daily (Weight × 0.25) ÷ 0.75 mg/mL
≥2 years, ≥20 kg 5 mg daily (flat dose) 6.7 mL daily or one 5 mg tablet

Critical: Always round liquid doses to nearest 0.1 mL and document the calculation method.

Clean Prior Authorization Anatomy

A complete UnitedHealthcare PA request for Evrysdi should include:

Required Clinical Documentation

  1. Genetic Testing Results
    • SMN1 gene mutation/deletion confirmation
    • SMN2 copy number (if available)
    • Laboratory report with patient identifiers
  2. Motor Function Assessment
    • Age-appropriate scale: CHOP INTEND, HFMSE, RULM, or MFM-32
    • Baseline scores with date of assessment
    • Neurologist's interpretation
  3. Treatment History
    • Prior SMA therapies (Spinraza, Zolgensma)
    • Outcomes and reasons for discontinuation
    • Contraindications to other treatments
  4. Prescriber Information
    • Neurologist with SMA experience
    • Consultation notes and treatment plan
    • Monitoring schedule

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for specialty medications like Evrysdi. Their platform ingests denial letters and clinical notes to draft point-by-point rebuttals aligned to each payer's specific requirements, potentially saving weeks in the approval process.

Frequent Coding and Billing Pitfalls

Common Errors That Trigger Denials

Error Type Problem Solution
Weight Documentation Outdated or missing weight Use weight from within 30 days of prescription
Unit Conversion Pounds instead of kilograms Always convert to kg: weight (lbs) ÷ 2.2
Dose Calculation Math errors in mg or mL Double-check: mg dose ÷ 0.75 = mL volume
ICD-10 Mismatch Generic G12.9 without justification Use specific code matching genetic results
Concurrent Therapy Billing with active Spinraza Document discontinuation of other SMA treatments

Documentation Red Flags

  • Missing genetic confirmation
  • Baseline motor scores >6 months old
  • Concurrent SMN-targeting therapies
  • Incomplete neurologist consultation
  • Dosing exceeding FDA maximums
From our advocates: We've seen cases where a simple weight conversion error (using 44 lbs instead of 20 kg) resulted in a calculated overdose that triggered an automatic denial. Always double-check your math and include the calculation method in your documentation.

Verification with UnitedHealthcare Resources

Before Submitting Your Request

  1. Check Formulary Status
  2. Confirm PA Requirements
  3. Validate Coding
    • Confirm NDC numbers match current packaging
    • Cross-reference ICD-10 codes with genetic results
    • Verify prescriber NPI and specialty designation

Appeals Process in New Jersey

If UnitedHealthcare denies your Evrysdi request, New Jersey offers robust appeal rights through a structured process.

Internal Appeals (Required First)

  • Timeline: 180 days from denial date to file
  • Process: Submit through UnitedHealthcare member portal or by mail
  • Decision: 15 days standard, 72 hours for urgent requests
  • Required: Complete denial letter, medical records, physician letter

New Jersey IHCAP External Review

After exhausting internal appeals, you can request an independent external review through New Jersey's Independent Health Care Appeals Program (IHCAP).

IHCAP Process Details

  • Eligibility: Medical necessity denials after internal appeals
  • Deadline: 60 days after final internal denial
  • Cost: Free to consumers
  • Timeline: 45 days standard, 48 hours expedited
  • Decision: Binding on UnitedHealthcare

Required IHCAP Documentation

  • Final denial letter from UnitedHealthcare
  • All internal appeal correspondence
  • Complete medical records
  • Physician letter supporting medical necessity
  • IHCAP application form
Note: IHCAP reviews are conducted by independent physicians with appropriate specialty expertise. Success rates vary, but thorough documentation significantly improves outcomes.

For assistance with the IHCAP process, contact the New Jersey Department of Banking and Insurance at 1-800-446-7467 or the IHCAP hotline at 1-888-393-1062.

Quick Pre-Submission Checklist

Before submitting your Evrysdi prior authorization:

Clinical Documentation ✓

  • Genetic test results confirming SMN1 deletion/mutation
  • SMN2 copy number (if available)
  • Baseline motor function scores (within 6 months)
  • Neurologist consultation notes
  • Treatment history and contraindications

Coding and Billing ✓

  • Correct ICD-10 code matching genetic results
  • Accurate NDC for prescribed formulation
  • Weight-based dose calculation (show work)
  • Current patient weight in kilograms
  • Prescriber NPI and specialty verification

Administrative Details ✓

  • Complete PA form with all required fields
  • Patient demographics match insurance card
  • Submission method confirmed (portal/fax)
  • Copy retained for records
  • Follow-up plan if additional information requested

Costs and Financial Assistance

Evrysdi's annual cost can exceed $300,000, making financial assistance crucial for many families. Available options include:

  • Genentech Patient Foundation: Income-based assistance for eligible patients
  • Commercial copay support: Up to $15,000 annually for commercially insured patients
  • State pharmaceutical assistance programs: Check New Jersey's eligibility requirements
  • Nonprofit organizations: Cure SMA and other patient advocacy groups offer resources

Visit Counterforce Health for additional guidance on navigating insurance coverage and appeals for specialty medications.

FAQ: Common Questions

Q: How long does UnitedHealthcare PA take in New Jersey? A: Standard reviews take up to 15 days. Urgent requests are processed within 72 hours if medical necessity is demonstrated.

Q: What if Evrysdi is non-formulary on my plan? A: Request a formulary exception with documented medical necessity. Include evidence that formulary alternatives are ineffective or contraindicated.

Q: Can I request expedited review for my child? A: Yes, if delay would jeopardize health or function. Provide clinical documentation supporting urgency.

Q: Does step therapy apply if we've tried Spinraza? A: UnitedHealthcare typically requires documentation of prior therapy outcomes. Spinraza failure or intolerance may support Evrysdi approval.

Q: What happens if IHCAP overturns the denial? A: UnitedHealthcare must comply with the IHCAP decision and provide coverage. This is legally binding under New Jersey law.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan benefits and medical circumstances. Always consult your healthcare provider and insurance plan documents for specific guidance. For additional support with insurance appeals and prior authorizations, consider consulting Counterforce Health or contacting New Jersey's consumer assistance programs.

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