Prior Authorization Request (Rifaximin)

Patient name: [Patient full name]

Date of birth: [MM/DD/YYYY]

Member ID: [Health plan member ID]

Health plan name: [Payer name]

Prescriber name and credentials: [Prescriber full name, degrees]

NPI: [Prescriber NPI]

Practice name and address: [Practice/clinic name, street, city, state, ZIP]

Phone: [Prescriber office phone]

Fax: [Prescriber office fax]

Request type: [initial / renewal]; Urgency: [standard / expedited] (If expedited, briefly document rationale for potential harm from delay.)

Medication requested: rifaximin 550 mg tablets

Dose and frequency: 550 mg orally twice daily

Quantity for 30-day supply: 60 tablets

Number of refills: [Number of refills requested]

Planned duration: [Chronic maintenance / duration in months]

Start date: [Upon approval / MM/DD/YYYY]

Medical Necessity Summary

[Medical necessity narrative] (Write 5–8 sentences in paragraph form covering: 1) diagnosis of recurrent overt hepatic encephalopathy in the setting of cirrhosis; 2) severity and impact including confirmed episode count, hospitalizations, and functional or safety impairment; 3) standard therapy tried (lactulose) and why it is insufficient—recurrence despite optimization or intolerance limiting effective dosing; 4) why rifaximin is needed now—recent recurrence or high near-term risk, guideline-aligned secondary prophylaxis; 5) if episode count is uncertain, state that confirmed events are listed below rather than estimating.)

Diagnosis and Clinical Context

• Primary diagnosis: [Overt hepatic encephalopathy — recurrent / persistent]
• Underlying liver disease etiology: [Etiology] (e.g., alcohol-associated, viral hepatitis, NASH)
• Cirrhosis and portal hypertension: [Present / Not documented] (Include supporting evidence if available.)
• Portosystemic shunts/TIPS: [None / Present with details]
• Severity snapshot: Child-Pugh [A / B / C]; MELD-Na [score] as of [date]; Decompensations: [ascites / variceal bleeding / SBP / HRS with dates if available]
• Transplant status: [Listed / Referred / Not applicable]
• Living situation and caregiver support: [Living arrangement and caregiver availability] (Include if relevant to adherence or safety.)

OHE Episode History

(Cover at minimum the last 6–12 months. Do not assign West Haven grades unless explicitly documented in source records; describe observable features instead.)

Date	Setting	Clinical Features	Precipitant Identified	Interventions	Outcome
[MM/DD/YYYY]	[Outpatient / ED / Inpatient / ICU]	[Observable features without grading unless documented]	[Precipitant or "None identified"]	[Therapies given]	[Discharge disposition / clinical result]
[MM/DD/YYYY]	[Setting]	[Observable features]	[Precipitant or "None identified"]	[Therapies given]	[Outcome]

Total HE-related hospitalizations (last 6 months): [Number]

Total HE-related ED visits (last 6 months): [Number]

Total HE-related hospitalizations (last 12 months): [Number]

Total HE-related ED visits (last 12 months): [Number]

Safety events: [Falls / driving restrictions / medication mismanagement / work impairment / none documented] (List events and dates if available.)

(If records are unavailable, specify which events are confirmed by records versus patient-reported.)

Precipitating Factors Evaluation

(Indicate whether each was assessed, identified, action taken, and current status.)

• Infection (SBP/UTI/pneumonia): [Yes / No / Not assessed]; Action: [Action taken]; Status: [Resolved / Ongoing / N/A]
• GI bleeding: [Yes / No / Not assessed]; Action: [Action taken]; Status: [Resolved / Ongoing / N/A]
• Constipation/bowel regimen: [Yes / No]; Action: [Action taken]; Status: [At goal 2–3 soft stools daily / Not at goal]
• Dehydration/overdiuresis: [Yes / No]; Action: [Action taken]; Status: [Resolved / Ongoing / N/A]
• Electrolyte disturbance/renal dysfunction: [Yes / No]; Action: [Action taken]; Status: [Resolved / Ongoing / N/A]
• Medication triggers (benzodiazepines/opioids/sedatives): [Yes / No]; Action: [Action taken]; Status: [Resolved / Ongoing / N/A]
• TIPS/shunt considerations: [No TIPS or shunt / Present—details]

Summary: [No reversible precipitant identified as of MM/DD/YYYY / Reversible precipitant(s) addressed as documented above]

Lactulose Therapy and Limitations

• Start date or duration: [MM/DD/YYYY or approximate duration]
• Current dose and schedule: [Dose, route, frequency]
• Titration goal: 2–3 soft stools daily
• Adherence assessment: [Good / Variable / Poor / Uncertain]; [Self-administered / caregiver-administered]; Barriers: [None / barriers identified]
• Clinical response: [Effective when taken / Recurrence despite use / Uncertain] (Only state failure if documented.)
• Limitations/adverse effects: [Adverse effects limiting titration or adherence] (Include diarrhea, bloating, cramping, dehydration, incontinence risk, falls, electrolyte derangements with labs if available, clinician-directed dose reductions. If no limitations, state "None documented.")

(If adherence is uncertain, do not claim lactulose failure; document what is known and source of information.)

Rifaximin Request and Rationale

• Requested regimen: rifaximin 550 mg orally twice daily, chronic maintenance, as [add-on to lactulose / monotherapy if lactulose intolerance documented]
• Indication fit: Adult with cirrhosis and history of OHE requiring secondary prophylaxis
• Guideline alignment: AASLD/EASL recommend rifaximin as add-on therapy to reduce OHE recurrence and HE-related hospitalizations in patients with prior OHE
• Why alternatives are not appropriate: [Lactulose limitations as documented above; other antibiotics such as neomycin carry toxicity concerns and are not preferred for chronic prophylaxis]
• Patient-specific risk: [Summary of documented episodes and hospitalizations supporting near-term risk]
• Expected outcome: Reduce OHE recurrence and HE-related hospitalizations; improve outpatient stability and safety

Safety and Monitoring

• Allergies: [No known allergy to rifaximin or rifamycins / Allergy documented: details]
• History of C. difficile or severe antibiotic-associated diarrhea: [No / Yes—details]
• Hepatic impairment context: Child-Pugh [class]; MELD-Na [score] (Rifaximin is minimally absorbed.)
• Concomitant medications requiring monitoring: [Warfarin or other relevant medications / None]
• Pregnancy status: [Not applicable / Not pregnant / Pregnant—risk-benefit discussed]
• Monitoring plan: Follow-up in [interval]; monitor for OHE recurrence and mental status changes; track stool frequency if on lactulose; check electrolytes and renal function as indicated; assess adherence and adverse effects at each visit
• Renewal criteria (for renewal requests): [Document episodes reduced/avoided, hospitalizations decreased, and clinical stability since starting rifaximin]

Supporting Documentation

• [Recent hepatology/GI clinic note]
• [Discharge summaries for HE admissions]
• [ED notes for relevant visits]
• [Current medication list including lactulose dose and schedule]
• [Relevant labs if requested by payer]

(If documents are unavailable, state what was requested and provide interim summary from available records.)

Attestation

I attest that the information provided is accurate and supported by the patient's medical record. Please contact [clinician name and direct phone number] for peer-to-peer review if needed.

(If expedited request, add: This request is expedited due to [clinical rationale], as delay may reasonably be expected to result in [harm from delay].)