MedicaidPrior AuthLow impact
BT202265: IHCP updates PA criteria for HCPCS code J3399 (Zolgensma)
Indiana Medicaid (IHCP)·IN · Neurology, Pediatrics·Claims & Billing
Effective date
Aug 1, 2022
We identified it
Jun 19, 2026
Summary
Indiana Health Coverage Programs (IHCP) updated prior authorization criteria for Zolgensma (HCPCS J3399) to include patients with up to three copies of SMN2 gene, effective August 1, 2022. The updated criteria also specify detailed medical necessity requirements including genetic testing, age restrictions, and clinical status documentation.
Action Required
Indiana providers billing HCPCS J3399 (Zolgensma): Update prior authorization request procedures to include new medical necessity criteria requiring documentation of SMN2 gene copies (up to 3), genetic testing confirmation, anti-AAV9 antibody testing, gestational age verification, age under 2 years, and current clinical status scores. Submit PA requests to Gainwell Technologies at 800-457-4584 option 7. Claims without proper PA meeting updated criteria will be denied.