CurrentColorado Rocky Mountain Health PlansPolicy N/A

Albumin prior authorization — Florida Medicaid

Defines prior authorization requirements, allowed indications, documentation, and duration limits for albumin therapy under Florida Medicaid; intended for prescribers, pharmacies, and PA reviewers.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAlbumin prior authorization — Florida Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with progress notes, recent chart notes, and the most recent related labs; retain documentation for five years.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 monthsmaximum length of therapy

6approved indications listed

5documentation retention (yrs)

DeniedTPN use

Coverage Criteria

Initial authorization criteria

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAlbumin prior authorization — Florida Medicaid

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed prior authorization form with progress notes, recent chart notes, and the most recent related labs; retain documentation for five years.

SourceLink

On This Page

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Primary coverage criteria: 1) Prescriber submits a fully completed PA form with required progress notes, medical records indicating the diagnosis, and the most recent related labs; 2) The recipient has one of the approved diagnoses: Hypoalbuminemia due to Acute Liver Failure, Burns, Hepatic Cirrhosis, Nephrotic Syndrome, Trauma, or Tuberculosis; 3) Duration of therapy does not exceed 3 months; 4) Albumin will NOT be used in TPN solutions.Maximum length of therapy: 3 months

Provider must retain documentation for five years.

Do not approve albumin for caloric supplementation or as an additive to total parenteral nutrition (TPN). The PA form specifically asks whether albumin will be used in TPN solutions and states that if the answer is Yes, PA will be denied.

Providers should ensure that albumin is not ordered or billed for the purpose of providing calories or mixed into TPN solutions; such uses are excluded from coverage under this policy.

Covered Indications

Hypoalbuminemia due to Acute Liver Failure

Hypoalbuminemia due to Acute Liver Failure - coverage details: Diagnosis of hypoalbuminemia due to acute liver failure documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Hepatic Cirrhosis

Hepatic Cirrhosis - coverage details: Diagnosis of hepatic cirrhosis documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Nephrotic Syndrome

Nephrotic Syndrome - coverage details: Diagnosis of nephrotic syndrome documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Tuberculosis

Tuberculosis - coverage details: Diagnosis of tuberculosis documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Trauma

Trauma - coverage details: Diagnosis of trauma documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Burns

Burns - coverage details: Diagnosis of burns documented in the medical record and recent chart notes; prescriber provided most recent related labs and completed PA form.

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required — approval limited to listed indications and maximum therapy length of 3 months. Incomplete forms or missing records may result in denial.

Approval limited to the approved indications listed by the payer
Maximum therapy length: 3 months

Step Therapy

No step-therapy rules specified for this policy.

Documentation Required

Required Documentation

Form must be completed in full and include progress notes, medical records indicating the diagnosis, and the most recent related labs. The provider must retain copies of all documentation for five years. Fax completed form to 1-866-940-7328 or contact Pharmacy PA Call Center at 1-800-310-6826.

Required: Completed PA form with patient and prescriber identifiers (Medicaid ID, DOB, patient name, prescriber name, NPI, phone, fax)
Required: Progress notes and medical records documenting the diagnosis
Required: Most recent related laboratory results
Retention: Providers must retain documentation for 5 years
Submission: Fax to 1-866-940-7328; Pharmacy PA Call Center: 1-800-310-6826

Denial Risk

TPN Use Denies Authorization

If albumin will be used as an additive in TPN solutions, prior authorization will be denied.

If 'Yes' to "Will Albumin be used in TPN solutions?" → PA denied
Do not approve albumin for caloric supplementation or as an additive to TPN

Ordering Requirements

Note

Ordering requirements — submit completed PA form and records

The prescriber must complete and sign the PA form and fax it with all required supporting medical records and the most recent related labs for review; the policy does not restrict ordering to any specific provider specialty.

Fax completed form and records to 1-866-940-7328.
Include diagnostic evaluations, recent chart notes, and related labs with the submission.

Not Covered / Exclusions

NOT COVERED: Albumin used for caloric supplementation or administered as an additive to TPN solutions. The PA form requires the prescriber to indicate whether albumin will be used in TPN; if so, the request is denied.

Requests for albumin where documentation shows intent to mix with or add to TPN must be denied and should not be approved under any covered indication.

Background

Albumin is an intravenous blood product used to treat hypoalbuminemia and for intravascular volume expansion in specific acute conditions. This PA policy restricts coverage to the listed approved indications (Hypoalbuminemia due to Acute Liver Failure, Burns, Hepatic Cirrhosis, Nephrotic Syndrome, Trauma, and Tuberculosis) and limits therapy duration to a maximum of 3 months per approval.

The policy requires a fully completed PA form and submission of supporting documentation — progress notes, recent chart notes, and the most recent related laboratory results — and notes that providers must retain copies of all documentation for five years. The form also includes an explicit exclusion: albumin intended for use in TPN solutions will result in PA denial.

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