CurrentColorado Rocky Mountain Health PlansPolicy N/A

Prior authorization and medical necessity criteria for Enbumyst, Furoscix, and Lasix ONYU

Prior authorization and medical necessity criteria for Enbumyst (bumetanide nasal spray), Furoscix (furosemide injection) and Lasix ONYU (furosemide injection) for treatment of edema; applies to Colorado Rocky Mountain Health Plans members and providers managing outpatient use of these agents.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPrior authorization and medical necessity criteria for Enbumyst, Furoscix, and Lasix ONYU

Policy CodePolicy N/A

Change TypeAdded productsclarified Furoscix pediatric-onlyrevised indications

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization with documentation of background loop diuretic use and, for Lasix ONYU, document trial/failure/contraindication to Enbumyst.

SourceLink

POLICY UPDATE CHANGES

Added Enbumyst and Lasix ONYU to criteria.

Updated Furoscix to note it is typically excluded and coverage will only be provided for pediatric patients.

Updated background to add limitations of use and to add CKD indication; removed creatinine clearance requirements previously present.

3medications covered by this program

1 moinitial authorization duration

pediatric-onlyFuroscix coverage population

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Coverage Criteria

Initial Therapy - Enbumyst and Lasix ONYU

Covered when ALL of the following are met:

Primary diagnosis: Edema associated with one of: (1) congestive heart failure, (2) renal disease including nephrotic syndrome, or (3) hepatic disease.

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Setting: Patient does not require ongoing emergency care or hospitalization.

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Background therapy: Submission of medical records confirming the patient is established on background loop diuretic therapy (e.g., bumetanide, furosemide, torsemide) for treatment of edema.

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Outpatient candidacy: Patient is a candidate for parenteral or nasal diuresis outside of the hospital (i.e., outpatient setting).

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Prescriber specialty: Prescribed by or in consultation with one of the following: cardiologist, nephrologist, hepatologist, or gastroenterologist.

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Lasix ONYU specific: For Lasix ONYU only: trial, failure, or contraindication to Enbumyst is required.

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Initial Therapy - Furoscix (pediatric)

Covered when ALL of the following are met:

Age: Patient is less than 18 years of age.<18 years

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Population restriction: Furoscix is typically excluded for adults; coverage will only be provided for pediatric patients.

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The policy notes that Furoscix (furosemide injection) is typically excluded for adult patients. Coverage of Furoscix will only be provided for pediatric patients, and adult requests may be denied.

Initial Therapy Rules

Initial therapy rules

Initial approval conditions:

Diagnosis: Edema from congestive heart failure, renal disease (including nephrotic syndrome), or hepatic disease.

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Background loop diuretic: Documentation (medical records) that the patient is established on background loop diuretic therapy (e.g., bumetanide, furosemide, torsemide) for treatment of edema.

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Outpatient candidacy and prescriber: Patient is a candidate for parenteral or nasal diuresis outside of the hospital and therapy is prescribed by or in consultation with an appropriate specialist (cardiologist, nephrologist, hepatologist, or gastroenterologist).

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required and will be approved only when ALL listed clinical criteria are met, including a diagnosis of edema due to congestive heart failure, renal disease (including nephrotic syndrome), or hepatic disease; documentation that the patient is established on background loop diuretic therapy; the patient does not require ongoing emergency care or hospitalization and is a candidate for outpatient parenteral or nasal diuresis; and the medication is prescribed by or in consultation with an appropriate specialist (cardiologist, nephrologist, hepatologist, or gastroenterologist).

Affected products: Enbumyst, Lasix ONYU
Required documentation: medical records confirming background loop diuretic use (e.g., bumetanide, furosemide, torsemide)
Setting: patient must be a candidate for parenteral or nasal diuresis outside the hospital
Prescriber: prescribed by or in consultation with cardiologist, nephrologist, hepatologist, or gastroenterologist

Step Therapy Requirements

Step	Requirement
1	Trial, failure, or documented contraindication to Enbumyst is required before approval of Lasix ONYU.

Quantity Limits

Quantity limits / thresholds

Supply limitsSupply limits may be in place for products in this program.

Authorization duration (example)Initial authorizations may be issued for limited durations (e.g., 1 month for Furoscix per policy).

Automated approvalsUnitedHealthcare may approve initial and reauthorization based on previous claim/medication history, diagnosis codes, or claim logic which can affect applied limits.

Background

Enbumyst (bumetanide nasal spray), Furoscix (furosemide injection), and Lasix ONYU (furosemide injection) are classified as loop diuretics and are indicated for treatment of edema associated with congestive heart failure, renal disease including nephrotic syndrome, and hepatic disease in specified populations.

The policy clarifies that while these agents share class indications, Furoscix is typically excluded for adults and will only be covered for pediatric patients; program rules also note that supply limits may be in place and that prior authorization or automated approval may rely on prior claim/medication history and diagnosis codes.

Definitions and Indications

Loop diuretics (class)

Class nameLoop diuretics

Primary actionDiuretics that act on the loop of Henle to promote diuresis for treatment of edema.

Common agents (in this policy)Enbumyst (bumetanide nasal spray), Furoscix (furosemide injection), Lasix ONYU (furosemide injection).

Typical indications (class-level)Treatment of edema associated with congestive heart failure, renal disease (including nephrotic syndrome), and hepatic disease.

Indications (product-specific)

General indicationsEdema associated with congestive heart failure, renal disease (including nephrotic syndrome), and hepatic disease; product-specific populations apply.