Billing and Coding: Spinraza® (nusinersen)

Nusinersen (SPINRAZA®, HCPCS J2326) is billed for intrathecal administration (CPT 96450) and covered when the patient has a documented SMA diagnosis billed as primary ICD-10-CM G12.0 or G12.1. FDA‑approved dosing is 12 mg (5 mL) per intrathecal dose with a maximum of six doses in the first 12 months and up to three doses in any subsequent rolling 12-month period; any deviations in diagnosis, dose, or frequency require additional medical necessity documentation and will be reviewed on a claim-by-claim basis.

"Nusinersen (SPINRAZA®, HCPCS J2326) is covered when administered intrathecally for patients fully evaluated and diagnosed with spinal muscular atrophy (SMA) identified by primary ICD-10-CM code G12."

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