085 Form

Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy (SMA) Prior Authorization Request Form #085

Medical Policy #008 Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy (SMA)

CLINICAL DOCUMENTATION ▪ Clinical documentation that supports the medical necessity criteria for Zolgensma (onasemnogene abeparvovec-xioi) for Spinal Muscular Atrophy (SMA) must be submitted.
▪ If the patient does not meet all the criteria listed below, please submit a letter of medical necessity with a request for Clinical Exception (Individual Consideration) explaining why an exception is justified.

Requesting Prior Authorization Using Authorization Manager Providers will need to use Authorization Manager to submit initial authorization requests for services. Authorization Manager, available 24/7, is the quickest way to review authorization requirements, request authorizations, submit clinical documentation, check existing case status, and view/print the decision letter. For commercial members, the requests must meet medical policy guidelines.

To ensure the request is processed accurately and quickly: • Enter the facility’s NPI or provider ID for where services are being performed. • Enter the appropriate surgeon’s NPI or provider ID as the servicing provider, not the billing group.

Authorization Manager Resources • Refer to our Authorization Manager page for tips, guides, and video demonstrations.

Complete Prior Authorization Request Form for Zolgensma (085) using Authorization Manager.

For out of network providers: Requests should still be faxed to 888-973-0726.

Patient Information Patient Name:

Today’s Date: BCBSMA ID#:

Date of Treatment: Date of Birth:

Place of Service: Outpatient  Inpatient 

Physician Information Facility Information Name:

Name:
Address:

Address: Phone #:

Phone #: Fax#:

Fax#: NPI#:

NPI#:

Please check off if the patient meets ALL of the following conditions:

• 2 -

  1. Diagnosis of SMA confirmed by genetic testing demonstrating bi-allelic mutations in the survival motor neuron 1 (SMN1) gene (examples below):

  a. deletion of both copies of the SMN1 gene; OR b. compound heterozygous mutations of the SMN1 gene (defined below): i. pathogenic variant(s) in both copies of the SMN1 gene; OR ii. pathogenic variant in one copy and deletion of the second copy of the SMN1 gene.

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  2. Documentation of a genetic test confirming no more than 4 copies of the SMN2 gene

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  3. Member must be ≤2 years of age

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  4. Documentation of baseline laboratory assessments such as ALT, AST, total bilirubin and prothrombin time

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  5. Member does not have advanced spinal muscular atrophy (e.g., complete paralysis of limbs, permanent ventilator dependence)

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  6. Confirmation of baseline anti-adeno-associated virus serotype 9 (AAV9) antibody titers < 1:50

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  7. Zolgensma must be prescribed by a neurologist with expertise in treating SMA

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  CPT CODES/ HCPCS CODES/ ICD CODES HCPCS codes: Code Description C9399 Unclassified drugs or biologicals  J3490 Unclassified drugs  J3590 Unclassified biologics 

  Providers should enter ICD10 Procedure codes below: Code Description XW033F3 Introduction of Other New Technology Therapeutic Substance into Peripheral Vein, Percutaneous Approach, New Technology Group 3 

  Providers should enter the relevant diagnosis code(s) below: Code Description G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman] 