By Counterforce Health Team in Spinraza (nusinersen) —

The Requirements Checklist to Get Spinraza (nusinersen) Covered by Humana in Ohio: Forms, Appeals, and Approval Timeline

Answer Box: Getting Spinraza Covered by Humana in Ohio

Fastest path to approval: Humana requires prior authorization for Spinraza (nusinersen) with genetic testing confirming SMN1 deletion, baseline motor function assessment, and neurologist prescription. Submit through Humana's provider portal with complete documentation. If denied, you have 65 days for internal appeal, then 180 days for Ohio external review. Start today: Contact your neurologist to gather genetic test results and request a letter of medical necessity. Humana prior authorization portal.

Table of Contents

  1. Who Should Use This Checklist
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding and Billing Requirements
  5. Documentation Packet Essentials
  6. Submission Process
  7. Appeals Process in Ohio
  8. Common Denial Reasons & Solutions
  9. Printable Checklist
  10. FAQ

Who Should Use This Checklist

This guide is for Ohio residents with Humana Medicare Advantage or commercial plans who need Spinraza (nusinersen) coverage for spinal muscular atrophy (SMA). You'll also find this helpful if you've received a denial and need to file an appeal.

Expected outcome: With complete documentation meeting Humana's criteria, most appropriate requests receive approval. Humana's Medicare Advantage denial rate is approximately 3.5%—among the lowest of major insurers—but denials often occur due to incomplete documentation rather than medical necessity disputes.

Member & Plan Basics

Coverage Verification

  • Active Humana coverage required (Medicare Advantage, commercial, or dual-eligible special needs plan)
  • Verify formulary placement: Spinraza requires prior authorization on all Humana plans
  • Medical vs. pharmacy benefit: Spinraza is covered under medical benefit (not prescription drug benefit)
  • Deductible applies: Check if your medical deductible has been met

Plan-Specific Requirements

Humana Medicare Advantage members must use in-network providers and facilities for administration. Commercial plan members should verify network status of their neurologist and infusion center.

Clinical Criteria Requirements

Diagnosis Confirmation

Required: Genetic testing documenting bi-allelic SMN1 gene deletion or mutation confirming 5q spinal muscular atrophy. Clinical symptoms alone are insufficient—genetic confirmation is mandatory regardless of presentation.

ICD-10 codes:

  • G12.0: Infantile spinal muscular atrophy, Type I
  • G12.1: Other inherited spinal muscular atrophy (Types II, III, IV)

Motor Function Documentation

Baseline assessment required using standardized scales:

  • HFMSE (Hammersmith Functional Motor Scale Expanded) for ambulatory patients
  • RULM (Revised Upper Limb Module) for upper limb function
  • CHOP-INTEND for infants with Type I SMA
  • Six-Minute Walk Test when appropriate

Prescriber Requirements

  • Board-certified neurologist (required)
  • Preferably with SMA or neuromuscular disease expertise
  • Primary care physicians cannot prescribe for insurance approval

Exclusion Criteria

  • Permanent ventilator dependence (>16 hours daily)
  • Concurrent use with other SMA disease-modifying therapies (Zolgensma, Evrysdi) unless specifically approved

Coding and Billing Requirements

HCPCS and Procedure Codes

  • J2326: Injection, nusinersen, 0.1 mg (120 units per 12 mg dose)
  • 96450: Intrathecal injection procedure code
  • NDC: 64406-0058-01 (12 mg/5 mL vial)

Billing Requirements

  • Submit as medical claim (CMS 1500 form)
  • Include provider NPI number
  • Use appropriate place of service code for outpatient facility
Note: Spinraza cannot be billed through retail pharmacy—it must be administered in clinical settings with appropriate monitoring.

Documentation Packet Essentials

Core Documents Required

  1. Genetic test results confirming SMN1 deletion/mutation
  2. Baseline motor function assessment scores
  3. Neurologist consultation notes with SMA type classification
  4. Letter of medical necessity (see template requirements below)
  5. Previous treatment history and medication trials
  6. Current clinical status and functional abilities

Letter of Medical Necessity Components

Your neurologist's letter must include:

  • Patient demographics and Humana member ID
  • Confirmed SMA diagnosis with genetic testing results
  • SMN2 copy number (when available)
  • Baseline motor function scores with specific test names and dates
  • Treatment plan including loading dose schedule (Days 0, 14, 28, 63) and maintenance dosing (every 4 months)
  • Clinical rationale for treatment
  • Monitoring plan for safety parameters

Counterforce Health helps patients and clinicians create comprehensive appeals packages that address payer-specific requirements, turning denials into targeted, evidence-backed approvals by identifying the exact denial basis and crafting point-by-point rebuttals.

Submission Process

Submission Methods

Preferred: Humana Provider Portal Alternative options:

  • Fax: 502-508-9300
  • Phone: 866-421-5663 (Medicare requests)

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

Required Fields That Cause Rejections

  • Missing provider NPI number
  • Incorrect member ID or demographic information
  • Incomplete genetic testing documentation
  • Missing baseline motor function scores
  • Unsigned letter of medical necessity

Appeals Process in Ohio

Internal Appeal (First Level)

  • Deadline: 65 days from denial notice
  • Timeline: Humana has 30 days for standard appeals, 72 hours for expedited
  • Submit to: Same channels as initial request with "APPEAL" clearly marked

Ohio External Review (Second Level)

  • Deadline: 180 days from final internal denial
  • Process: File with your health plan, which notifies Ohio Department of Insurance
  • Timeline: 30 days for standard review, 72 hours for expedited
  • Authority: Independent Review Organization (IRO) decision is binding on Humana

Ohio Department of Insurance Contact

Consumer hotline: 1-800-686-1526 Website: Ohio Department of Insurance Appeals (verify current link)

Ohio-specific advantage: Even if Humana claims your case isn't eligible for external review, the Ohio Department of Insurance can independently determine eligibility and order a review.

Common Denial Reasons & Solutions

Denial Reason Solution Required Documents
Missing genetic confirmation Submit SMN1 deletion/mutation test results Genetic lab report with bi-allelic findings
Insufficient motor documentation Provide baseline assessment scores HFMSE, RULM, or other standardized test results
Non-specialist prescriber Transfer care to neurologist New prescription from board-certified neurologist
Incomplete medical necessity Enhanced letter addressing all criteria Comprehensive letter covering diagnosis, prognosis, treatment plan
Concurrent SMA therapy Document discontinuation or exception request Records showing other therapy stopped or clinical justification

Printable Checklist

Before Submission ✓

  • Active Humana coverage verified
  • Genetic test results obtained (SMN1 deletion/mutation)
  • Baseline motor function assessment completed
  • Board-certified neurologist consultation scheduled
  • Letter of medical necessity requested from neurologist
  • Prior therapy documentation gathered (if applicable)
  • Humana member ID and provider NPI confirmed

Submission Package ✓

  • Complete prior authorization form
  • Genetic testing report
  • Motor function assessment scores
  • Neurologist's letter of medical necessity
  • Previous treatment records
  • Patient demographics and insurance information
  • Correct coding (J2326, 96450, NDC)

After Submission ✓

  • Confirmation number recorded
  • Status check scheduled (10-14 days)
  • Appeal deadline noted (65 days if denied)
  • Contact information for Ohio Department of Insurance saved

FAQ

How long does Humana prior authorization take for Spinraza in Ohio? Standard review takes up to 30 days. Expedited review (when medically urgent) takes 48-72 hours. Incomplete submissions may be denied immediately without review.

What if Spinraza is non-formulary on my Humana plan? Spinraza requires prior authorization on all Humana plans but is typically covered when medical necessity criteria are met. Non-formulary status can be appealed with clinical justification.

Can I request an expedited appeal in Ohio? Yes, if waiting for a standard decision could seriously harm your health. Include a supporting statement from your prescribing neurologist explaining the clinical urgency.

Does step therapy apply to Spinraza? Humana may require documentation of previous SMA treatments or contraindications to other therapies. This varies by plan and clinical presentation.

What happens if my external review is denied in Ohio? The IRO decision is binding on Humana, but you retain rights to seek other remedies including regulatory complaints or legal action.

How much does Spinraza cost with Humana coverage? Costs vary by plan. After prior authorization approval, your out-of-pocket costs depend on your deductible, coinsurance, and out-of-pocket maximum. Contact Humana member services for specific cost estimates.

From our advocates: We've seen cases where patients received quick approvals by ensuring their neurologist included specific motor function scores and SMN2 copy numbers in the initial request. Taking time to gather complete documentation upfront often prevents the need for appeals altogether.

For complex cases requiring targeted appeals, Counterforce Health specializes in turning insurance denials into evidence-backed approvals by analyzing denial letters and plan policies to craft point-by-point rebuttals that align with each payer's specific requirements.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on individual circumstances and plan terms. Always consult with your healthcare provider and insurance company for guidance specific to your situation. For assistance with Ohio insurance issues, contact the Ohio Department of Insurance at 1-800-686-1526.

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