Download Spinraza

REVIEW REQUEST FOR
SPINRAZA™ (Nusinersen)
Provider Data Collection Tool Based on Medical Policy DRUG.00104
Policy Last Review Date: 02/02/2017
Request Date:
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Initial Request
Buy and Bill
Policy Effective Date:
02/16/2017
Provider Tool Effective Date:
01/21/2017
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Subsequent Request
Individual’s Name:
Date of Birth:
/
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Individual’s Phone Number:
Insurance Identification Number:
Primary Diagnosis:
Diagnosis Code(s) (if known):
Ordering Provider Name & Specialty:
Individual’s Weight
(lbs) (kg)
Provider ID Number (if known):
Office Address:
Office Phone Number:
Office Fax Number:
Servicing Provider Name & Specialty (If different than Ordering Provider):
Provider ID Number (if known):
Office Address:
Office Phone Number:
Office Fax Number:
Place of Service:
Home
Office
Dialysis Center
Outpatient Hospital
Ambulatory Infusion
Ambulatory Infusion Center
Other:
Drug Name/HCPCS Code (if known)
Dose to be administered:
(mg)
SPINRAZA™ (Nusinersen)
J3490
Other
Other:
When did the individual first start this drug?
Frequency (Days, Wks, Months)
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Duration:
Start Date For This Request:
(Weeks)
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This data collection tool is intended to facilitate a medical necessity review request for initial and continued use of
Nusinersen (SPINRAZA™) in the treatment of spinal muscular atrophy.
1) Initial Request for Treatment
Request is for an initial 6 months of Nusinersen (SPINRAZA™) treatment of an individual diagnosed with
confirmed spinal muscular atrophy If checked, please mark all of the following that apply:
Individual’s spinal muscular atrophy diagnosis has been confirmed and documented by:
SMA diagnostic test results confirming 0 copies of SMN1
Molecular genetic testing of 5q SMA for homozygous gene deletion
Molecular genetic testing of 5q SMA for homozygous conversion mutation
Molecular genetic testing of 5q SMA for compound heterozygote
Genetic testing confirming no more than 2 copies of SMN2
SMA-associated symptoms before 6 months of age
Other: (if checked please list the confirming test)
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REVIEW REQUEST FOR
SPINRAZA™ (Nusinersen)
Provider Data Collection Tool Based on Medical Policy DRUG.00104
Policy Last Review Date: 02/02/2017
Policy Effective Date:
02/16/2017
Provider Tool Effective Date:
01/21/2017
2) Request for Continued Treatment
Request is for an additional 6 months of Nusinersen treatment, beyond the initial 6 months of treatment,
of an individual diagnosed with confirmed spinal muscular atrophy
Request is for continued Nusinersen treatment at 6 month intervals
If either of the above is checked, please mark all of the following that apply:
A clinically significant improvement in the individual’s spinal muscular atrophy symptoms, compared to the
predicted natural history trajectory of disease, has been documented
Individual’s diagnosis of spinal muscular atrophy has been confirmed and documented by: (Check all that apply)
SMA diagnostic test results confirming 0 copies of SMN1
Molecular genetic testing of 5q SMA for homozygous gene deletion
Molecular genetic testing of 5q SMA for homozygous conversion mutation
Molecular genetic testing of 5q SMA for compound heterozygote
Genetic testing confirming no more than 2 copies of SMN2
SMA-associated symptoms before 6 months of age
Other: (if checked please list the confirming test)
3)
Other Use(s) (Please submit all supporting documents including labs, progress notes, imaging, etc., for
review.)
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the time of this
request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the
information reported on this form.
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Name & Title of Provider or Provider Representative Completing Form
Date
& attestation (Please Print)*
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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