Medicare AdvantagePrior AuthMedium impact
Rebyota™ (fecal microbiota, live-jslm) (Revised)
Humana·Gastroenterology, Infectious Disease, Internal Medicine·Medicare Advantage
Effective date
Nov 26, 2025
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage revised its prior authorization policy for Rebyota (fecal microbiota, live-jslm) effective November 26, 2025. The policy establishes six mandatory clinical criteria for coverage, including age 18+, positive C. difficile toxin test within 30 days, minimum 2 prior recurrent CDI episodes (3+ total episodes), completed antibiotic course, controlled current infection, and administration within 24-72 hours post-antibiotic. Prior authorization is required for all Rebyota enema claims.
Action Required
By November 26, 2025: Billing team must implement prior authorization requirement for all Rebyota (fecal microbiota, live-jslm) enema claims submitted to Humana Medicare Advantage plans. Update billing system and encounter documentation to verify all six eligibility criteria before claim submission: (1) patient age ≥18 years, (2) positive C. difficile toxin test within 30 days, (3) ≥2 prior recurrent CDI episodes documented, (4) completion of full antibiotic course (vancomycin or fidaxomicin), (5) current CDI episode controlled, and (6) Rebyota administration scheduled within 24-72 hours of antibiotic completion. Train providers and clinical staff on the timing requirement (24-72 hour window post-antibiotic). Route all claims through prior authorization process via Humana PAL (Preauthorization and Notification List) at www.humana.com/PAL. Claims submitted without prior authorization or missing any criteria will be denied. For medically billed requests, reference applicable coding information on Humana PAL website.