CurrentUnitedHealthcarePolicy N/A

Furoscix (furosemide injection) prior authorization

Defines prior authorization and medical necessity criteria for Furoscix (furosemide injection) for treatment of edema in adults with chronic heart failure or chronic kidney disease; applies to UnitedHealthcare pharmacy clinical programs and affected members/providers.

Policy Summary

PayerUnitedHealthcare

PolicyFuroscix (furosemide injection) prior authorization

Policy CodePolicy N/A

Change TypeUpdated: added CKDremoved creatinine clearance and NYHA class specifics

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit medical records showing the patient is established on background oral diuretic therapy to support prior authorization.

SourceLink

POLICY UPDATE CHANGES

Updated background and added criteria for chronic kidney disease (CKD) per updated indication; removed creatinine clearance requirements.

Updated background and removed criteria for NYHA Class II and Class III chronic heart failure per updated indication that includes NYHA Class IV chronic heart failure.

Added CKD as an eligible diagnosis for Furoscix.

1 monthauthorization duration on approval

Adultsindicated patient population

2listed qualifying diagnoses

Yesbackground diuretic required

Coverage Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Authorization for Furoscix: Patient has a diagnosis of chronic heart failure OR chronic kidney disease (CKD).

derived from listed qualifying diagnoses

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

medical record documentation required

Clinical setting: Patient is not in ongoing emergency care or hospitalized AND is a candidate for parenteral diuresis outside of the hospital.

both conditions required

Policy Summary

PayerUnitedHealthcare

PolicyFuroscix (furosemide injection) prior authorization

Policy CodePolicy N/A

Change TypeUpdated: added CKDremoved creatinine clearance and NYHA class specifics

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionSubmit medical records showing the patient is established on background oral diuretic therapy to support prior authorization.

SourceLink

On This Page

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Prescriber involvement: Furoscix is prescribed by or in consultation with a nephrologist or cardiologist.

specialist involvement required

Patients who are currently requiring ongoing emergency care or are hospitalized are excluded from outpatient authorization for Furoscix. The authorization criteria specify that the patient must not be in ongoing emergency care or inpatient status and must be a candidate for parenteral diuresis outside the hospital.

Use of Furoscix for outpatient authorization is not consistent for patients who are not established on a background oral loop diuretic regimen. The policy requires submission of medical records confirming the patient is established on background oral diuretic therapy (e.g., bumetanide, furosemide, torsemide) for edema management, and absence of that documentation or an inpatient/emergency care setting may lead to the use being considered not medically necessary for outpatient treatment.

Initial Therapy — Authorization Conditions

Initial Therapy

Initial authorization will be approved when all criteria below are met.

Diagnosis of chronic heart failure OR chronic kidney disease (including nephrotic syndrome).

from indication and criteria

Background therapy: Patient is established on background oral diuretic therapy (e.g., bumetanide, furosemide, torsemide) with supporting medical records.

documentation must be submitted

Care setting: Patient is not in ongoing emergency care or hospitalized AND is a candidate for parenteral diuresis outside the hospital.

both conditions required

Prescriber requirement: Prescribed by or in consultation with a nephrologist or cardiologist.

specialist involvement required

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Furoscix will be approved only if all listed criteria are met, including a qualifying diagnosis, documentation confirming the patient is established on background oral diuretic therapy, and that treatment is intended in an outpatient/administrative setting (patient is not currently requiring ongoing emergency care or hospitalization). Authorization will be issued for 1 month. State mandates, federal regulatory requirements, and the member's benefit plan may affect coverage.

Approval duration: 1 month
Affected drug: Furoscix
Background oral diuretics examples: bumetanide, furosemide, torsemide

Documentation Required

Documentation and Setting Requirements

Furoscix will only be considered when medical records clearly document that the patient is established on a background oral loop diuretic regimen (e.g., bumetanide, furosemide, torsemide) for treatment of edema. Submit clinical notes, medication history, and any recent relevant labs or outpatient encounter documentation to support this.

Required documentation: medical records confirming established background oral diuretic therapy
Include: medication start date, dosing, indication, and relevant outpatient progress notes

Step Therapy

Step Therapy Notes

Step therapy: patient must be established on background oral diuretic therapy prior to Furoscix initiation. There is no additional sequential step requirement specified beyond this prerequisite; no trial of another prescription diuretic is required if patient is already on an adequate oral loop diuretic regimen.

Step requirement: Established on background oral loop diuretic therapy before initiating Furoscix
No further explicit step sequence required

Denial Risk

Denial Risk — Missing Documentation or Inpatient Setting

Denial risk: lack of documentation confirming established background oral diuretic therapy or evidence that the patient currently requires ongoing emergency care or hospitalization may lead to denial of the request.

Missing medical records confirming background diuretic therapy
Documentation showing current inpatient status or ongoing emergency care

Step Therapy Requirements

Step	Requirement	Coverage
1	Submission of medical records confirming the patient is established on background oral diuretic therapy (e.g., bumetanide, furosemide, torsemide) for treatment of edema.	Patient must meet this requirement prior to approval

Site of Care and Setting Restrictions

Note

Site-of-care restriction: infusion center (outpatient only)

Furoscix is covered when used for outpatient parenteral diuresis in appropriate candidates; it is not authorized for patients who require ongoing emergency care or hospitalization.

Setting covered: outpatient parenteral diuresis (e.g., infusion center)
Not covered for patients requiring ongoing emergency care or hospitalization

Quantity Limits

Furoscix (furosemide injection) — Quantity Limits

Quantity limitSupply as approved (authorization will be issued for 1 month)

Limit period1 month authorization duration

Permonth

Definitions

Definition — Established on background diuretic therapy

DefinitionPatient has documented ongoing use of an oral loop diuretic (e.g., bumetanide, furosemide, torsemide) for treatment of edema.

Examples of oral loop diureticsBumetanide, furosemide, torsemide

Required evidenceSubmission of medical records confirming ongoing use of an oral loop diuretic for edema management.

PurposeConfirms patient is established on background diuretic therapy prior to outpatient Furoscix authorization.

Background

Furoscix (furosemide injection) is a loop diuretic indicated for edema in adult patients with chronic heart failure or chronic kidney disease and is intended for patients who are candidates for parenteral diuresis outside the hospital. Prior authorization is required and will be approved only when all criteria are met, including a qualifying diagnosis, documentation that the patient is established on background oral diuretic therapy, that the patient is not in ongoing emergency care or hospitalized, and that Furoscix is prescribed by or in consultation with a nephrologist or cardiologist. Authorization, when granted, is issued for 1 month.