By Counterforce Health Team in Spinraza (nusinersen) —

How to Get Spinraza (nusinersen) Covered by Humana in Michigan: Complete Prior Authorization Guide with Appeals Process

Quick Answer: To get Spinraza (nusinersen) covered by Humana in Michigan, you need prior authorization with genetic testing confirming SMA diagnosis, baseline motor function documentation, and neurologist prescription. If denied, you have 65 days for internal appeals, then 127 days for Michigan DIFS external review. Start today: Contact your neurologist to gather genetic test results and submit the prior authorization request through Humana's provider portal.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Requirements
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: Tracking Your Request
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in Michigan
  11. Cost Support Programs
  12. FAQ

Who Should Use This Guide

This guide is for Michigan residents with Humana Medicare Advantage or Part D coverage who need Spinraza (nusinersen) for spinal muscular atrophy (SMA). You'll find this helpful if you're:

  • Newly diagnosed with SMA and starting treatment
  • Facing a Humana denial for Spinraza coverage
  • Switching from another SMA medication
  • Moving to Michigan with existing Spinraza therapy

Expected outcome: With proper documentation and following this process, most medically appropriate Spinraza requests get approved. Humana's Medicare Advantage denial rate is relatively low at ~3.5%, and appeals are often successful when clinical criteria are met.

Member & Plan Basics

Coverage Requirements at a Glance

Requirement Details Source
Prior Authorization Required for all Humana plans Humana PA Lists
Formulary Status Specialty tier coverage Humana Drug Lists
Age Restrictions None (FDA-approved for pediatric and adult patients) FDA Label
Prescriber Requirements Board-certified/eligible neurologist Standard payer requirement
Site of Care Outpatient hospital or specialty clinic Intrathecal administration required

Plan Types and Deductibles

  • Medicare Advantage: Prior authorization required before deductible
  • Part D: May require step therapy or quantity limits
  • Dual Special Needs Plans: Additional state Medicaid coordination may apply

Clinical Criteria Requirements

Primary Diagnosis Requirements

Your doctor must document:

  • Confirmed SMA diagnosis with genetic testing showing bi-allelic SMN1 mutations or deletions
  • SMA type classification (Type I, II, III, or IV) based on clinical presentation
  • Absence of permanent ventilator dependence (>16 hours daily) for most coverage policies

Step Therapy Considerations

Some Humana plans may require trying other SMA treatments first:

  • Evrysdi (risdiplam) - oral medication
  • Zolgensma (onasemnogene abeparvovec) - one-time gene therapy
Note: Step therapy exceptions are available if other treatments are contraindicated or inappropriate based on patient age, disease severity, or previous treatment failures.

Baseline Function Documentation

Required assessments include:

  • Motor function scales (Hammersmith Functional Motor Scale, CHOP INTEND, or similar)
  • Current mobility status and assistive device use
  • Respiratory function if applicable
  • Previous treatment history and response

Coding and Billing Requirements

Essential Codes for Spinraza

Code Type Code Description Source
HCPCS J-code J2326 Injection, nusinersen, 0.1 mg CMS HCPCS
ICD-10 G12.0 Infantile spinal muscular atrophy, type I ICD-10-CM
ICD-10 G12.1 Other inherited spinal muscular atrophy ICD-10-CM
ICD-10 G12.8 Other spinal muscular atrophies ICD-10-CM

Dosing and Administration

  • Loading doses: Days 0, 14, 28, and 63
  • Maintenance: Every 4 months (3 times yearly)
  • Route: Intrathecal injection via lumbar puncture
  • Dose: 12 mg (5 mL) per administration

Documentation Packet Checklist

Required Medical Records

  • Genetic test results confirming SMN1 deletion/mutation
  • Baseline motor function assessment with standardized scale scores
  • Neurologist consultation notes with SMA type classification
  • Previous treatment history including failures or contraindications
  • Current clinical status and treatment goals

Letter of Medical Necessity Components

Your neurologist's letter should include:

  • Patient demographics and insurance information
  • Specific SMA diagnosis with genetic confirmation details
  • Clinical rationale for Spinraza over alternatives
  • Treatment plan including dosing schedule and monitoring
  • Expected outcomes and goals of therapy
Tip: Use the official Spinraza letter template and customize it with your specific clinical details.

Submission Process

How to Submit Your Prior Authorization

  1. Online Portal (preferred): Humana Provider Portal
  2. Fax: Check your specific plan documents for the correct fax number
  3. Phone: Contact Humana pharmacy prior authorization line (verify current number with your plan)

Required Fields That Commonly Cause Rejections

  • Complete patient demographics including Humana member ID
  • Prescriber NPI number and DEA (if applicable)
  • Specific ICD-10 codes matching the SMA diagnosis
  • Exact drug name, strength, and NDC number
  • Requested quantity and days supply
  • Clinical trial history or previous medication failures

Timeline Expectations

  • Standard review: Up to 30 days
  • Expedited review: 48-72 hours (requires urgent medical necessity documentation)
  • Incomplete submissions: May be denied without review

Specialty Pharmacy Routing

Humana's Preferred Specialty Pharmacy

CenterWell Specialty Pharmacy handles most Humana specialty medications, including Spinraza. Contact them at 1-800-486-2668 (TTY: 711).

Shipment Process

  1. Prior authorization approval must be obtained first
  2. CenterWell coordinates directly with your treatment facility
  3. Medication ships to the infusion center, not your home
  4. Treatment center schedules your intrathecal injection appointment
Important: Spinraza requires specialized handling and must be administered by qualified healthcare providers at approved facilities.

After Submission: Tracking Your Request

What to Record

  • Confirmation number from your submission
  • Date submitted and method used
  • Contact person at your doctor's office handling the request
  • Expected decision date based on standard or expedited timeline

Status Check Schedule

  • Week 1: Confirm receipt with Humana
  • Week 2: Check for any additional information requests
  • Week 3-4: Follow up if no decision received for standard review

Common Denial Reasons & How to Fix Them

Denial Reason How to Fix Required Documentation
Missing genetic confirmation Submit genetic test results SMN1 mutation/deletion report
Non-specialist prescriber Transfer to neurologist Board certification verification
Incomplete baseline assessment Provide motor function scores Standardized assessment results
Step therapy not attempted Request exception or document contraindications Medical necessity letter
Concurrent SMA therapy Discontinue other agents or justify combination Clinical rationale for dual therapy

Appeals Process in Michigan

Internal Humana Appeals

  • Deadline: 65 days from denial date
  • Method: Online, phone, or written appeal
  • Timeline: Standard appeals decided within 30 days
  • Expedited: 72 hours for urgent medical needs

Michigan External Review Process

If Humana's internal appeal is unsuccessful, Michigan residents can request an independent external review through the Department of Insurance and Financial Services (DIFS).

Key Details:

  • Deadline: 127 days from Humana's final denial
  • Cost: Free to patients
  • Timeline: Up to 60 days for standard review, 72 hours for expedited
  • Requirements: Must exhaust Humana's internal appeals first

How to File:

  1. Complete the DIFS external review form
  2. Include Humana's final denial letter
  3. Attach all supporting medical documentation
  4. For expedited review, include physician statement of urgent medical necessity

Contact DIFS:

When traditional insurance channels create barriers to essential medications, services like Counterforce Health help patients and clinicians navigate the complex prior authorization and appeals process. Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft compelling rebuttals that align with each payer's specific requirements.

Cost Support Programs

Manufacturer Assistance

  • Biogen Patient Support Program: May offer copay assistance for eligible patients
  • Contact: Check the official Spinraza website for current program details

Foundation Grants

  • Patient Access Network (PAN) Foundation: Provides copay assistance for qualifying patients
  • HealthWell Foundation: Offers grants for SMA treatments

CenterWell Specialty Pharmacy Financial Assistance

Contact CenterWell at 1-800-486-2668 to inquire about available financial assistance programs for Humana members.

FAQ

How long does Humana prior authorization take for Spinraza in Michigan? Standard prior authorization decisions are made within 30 days. Expedited reviews for urgent medical needs are completed within 48-72 hours.

What if Spinraza is not on my Humana formulary? You can request a formulary exception by submitting a letter of medical necessity demonstrating that formulary alternatives are not appropriate for your condition.

Can I request an expedited appeal in Michigan? Yes, both Humana and Michigan DIFS offer expedited appeals for urgent medical situations. Your doctor must provide a statement that delay would risk your health.

Does step therapy apply if I've tried other SMA medications outside Michigan? Yes, previous treatment history from other states should be documented and submitted with your prior authorization request to satisfy step therapy requirements.

What happens if both Humana's internal appeal and Michigan's external review deny coverage? You may have options for judicial review within 60 days of the DIFS decision, though this is rare and typically requires legal consultation.

How do I know if my Humana plan covers Spinraza? Check your plan's formulary or contact Humana member services. Most Medicare Advantage plans cover Spinraza on the specialty tier with prior authorization.

For complex cases involving multiple denials or unclear coverage policies, specialized services like Counterforce Health can help analyze your specific situation and develop a targeted strategy for securing coverage approval.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage details. Coverage policies and requirements may vary by plan and change over time. For personalized assistance with insurance appeals and coverage issues, contact the Michigan Department of Insurance and Financial Services at 877-999-6442.

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