Xifaxan He denied for missing prior authorization by Cigna?

Cigna's specific coverage criteria for xifaxan he are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Cigna Denied This as Requiring Prior Authorization

A prior-authorization-required denial means the prescription for rifaximin (Xifaxan) for hepatic encephalopathy (HE) was dispensed or billed without Cigna's advance approval, or a prior authorization request was submitted but denied because it did not satisfy Cigna's coverage criteria. This is a procedural and clinical hurdle combined: you must both follow the correct process and supply the right documentation.

Prior authorization denials for rifaximin in HE are common because Cigna places this medication on a managed tier requiring advance review. The good news is that the prior authorization process — and the appeal process when it is denied — is well-defined and frequently successful with complete documentation.

## Your Appeal Rights

• Internal appeal: You have the right to a full internal appeal of a prior authorization denial. Cigna must issue a decision within the timeframes mandated by your plan documents and applicable law.
• ACA §2719 external review: After exhausting internal levels, you may request independent external review. The external reviewer applies clinical standards to determine whether the denial was appropriate. You generally have approximately four months from the denial notice to request external review; confirm the exact date on your EOB.
• ERISA §503 full-and-fair review: Employer plans must provide all criteria used and must consider new clinical submissions.
• Expedited review: If waiting for a standard decision would seriously jeopardize your health or your ability to receive treatment, you can request expedited review simultaneously at the internal and external levels. Decisions on expedited requests must come within a compressed timeframe.

## Documentation to Gather

• Diagnosis and severity confirmation: Records documenting your HE diagnosis, any prior HE episodes, hospitalizations, and the severity of your condition as reflected in your chart.
• Prior-treatment history with dates and outcomes: A chronological list of HE-related treatments previously tried — dates, documented responses, and reasons for discontinuation or inadequacy. This is the most commonly missing element in denied PA requests.
• Prescriber medical-necessity letter: A detailed letter from your physician covering your diagnosis, disease course, prior treatments and their outcomes, why rifaximin is medically necessary for your specific presentation, and a reference to the applicable hepatology society guideline organization.
• Cigna's PA criteria: Download Cigna's prior authorization criteria and coverage policy for rifaximin-HE. Confirm your prescriber's letter addresses every criterion explicitly.

## Criteria-Mapping Approach

Cigna's prior authorization form and coverage policy list specific requirements. Obtain both documents from Cigna's provider or member portal. For each requirement, ensure your submission contains a direct, chart-supported answer. A letter that mirrors the structure of the PA criteria — addressing each point in order — is far more effective than a narrative letter that may inadvertently omit a required element.