Provider Briefing: Congestive Heart Failure (CHF) Pharmacotherapy Payer: Humana (Medicare Advantage & Commercial)
Plan Year: 2026
Focus: Guideline-Directed Medical Therapy (GDMT) & Medical Necessity Documentation

---

1. Code & Policy Identification

While most CHF medications are managed under Pharmacy Benefit (Part D), specific injectable therapies or high-acuity monitoring fall under Medical Benefit.

• Primary ICD-10 Codes: I50.2x (Systolic), I50.3x (Diastolic), I50.4x (Combined).
• Common Formulary Medications (GDMT):
  • ARNIs: Sacubitril/Valsartan (Entresto) – Typically Tier 3/4.
  • SGLT2 Inhibitors: Dapagliflozin (Farxiga), Empagliflozin (Jardiance) – Typically Tier 3.
  • Beta Blockers: Carvedilol, Metoprolol Succinate – Tier 1 (Preferred).
  • MRAs: Spironolactone, Eplerenone – Tier 1/2.
• Humana Policy Reference: Humana Pharmacy Management & GDMT Clinical Coverage Guidelines (2026 Update).

---

2. Authorization Status

• Generic GDMT (ACEi, ARBs, Beta Blockers, Diuretics): Generally No Prior Authorization (PA) required.
• Branded Agents (Entresto, Farxiga, Jardiance, Verquvo): Subject to Step Therapy (ST) or Prior Authorization.
• Post-Payment Audit Risk: High for patients prescribed branded SGLT2s without a documented diagnosis of HFrEF (Heart Failure with reduced Ejection Fraction) or Type 2 Diabetes.

---

3. The Documentation Checklist

To ensure coverage and audit-readiness, the SOAP note must explicitly state:

1. NYHA Functional Classification: Clearly document Class II, III, or IV. (Class I often fails medical necessity for branded ARNI/SGLT2 escalation).
2. LVEF (Left Ventricular Ejection Fraction): Must cite the most recent Echocardiogram or MUGA scan date and the specific percentage (e.g., "LVEF 35% per Echo on 01/15/2026").
3. Conservative Therapy Failure: Documentation of current or previous use of ACE inhibitors or ARBs, including the specific reason for discontinuation (e.g., "persistent cough," "hyperkalemia," or "symptomatic hypotension").

---

4. Denial Red Flags (Step Therapy Traps)

• The "ACE/ARB First" Rule: Humana 2026 guidelines typically deny Entresto unless the patient has a documented 30-day trial and failure of a generic ACE inhibitor (e.g., Lisinopril) or ARB (e.g., Losartan), OR a documented contraindication.
• The "Stable Dose" Requirement: Denials occur if the provider switches to a branded agent during an acute decompensation without noting that the patient was "hemodynamically stable" on a previous regimen first.
• Contraindication Exclusion: Automatic denial if Entresto is prescribed within 36 hours of an ACE inhibitor (due to angioedema risk) without a documented "washout period" plan.

---

5. Clinical Action Plan: "Audit-Proof" SmartPhrases

Situation	Recommended Documentation Phrase
Escalating to ARNI	"Patient remains symptomatic (NYHA Class II) despite 90-day trial of Lisinopril 20mg. Switching to Entresto to reduce risk of CV death and HF hospitalization per GDMT."
Adding SGLT2i	"LVEF remains <40% despite optimized Beta Blocker and ACEi therapy. Adding [Jardiance/Farxiga] for additional mortality benefit and renal protection."
Documenting Intolerance	"Generic ACE inhibitor (Lisinopril) discontinued due to [intractable cough/angioedema]. Patient started on ARB/ARNI as alternative first-line therapy."

Auditor’s Tip: Ensure the Problem List is updated to reflect the specific type of heart failure (e.g., "Chronic Systolic Heart Failure") rather than the generic "CHF" (I50.9), as specific medications are only FDA-approved/formulary-covered for specific LVEF ranges.