Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
This is an update to the article titled, "Onasemnogene Abeparvovec-xioi (Zolgensma) Criteria Effective October 1, 2019, for Texas Medicaid," which was published on this website September 6, 2019.
The article included documentation requirements for requesting prior authorization for onasemnogene abeparvovec-xioi (Zolgensma) when the client was previously prescribed nusinersen (Spinraza).
The documentation requirements have been updated to clarify only one of the criteria must be met, as follows:
- If nusinersen (Spinraza) (procedure code J2326) has been previously prescribed, the prescriber must provide documentation of one of the following before switching to onasemnogene abeparvovec-xioi (Zolgensma) therapy:
- Evidence of clinical deterioration (e.g., decreased physical function and CHOP-INTEND score) while on nusinersen (Spinraza) therapy
- Prescriber attestation to the discontinuation of nusinersen (Spinraza) therapy
For more information, call the TMHP Contact Center at 800-925-9126.