By Counterforce Health Team in Chenodal (chenodiol) —

Complete Guide to Getting Chenodal (Chenodiol) Covered by UnitedHealthcare in Ohio: Requirements, Appeals, and Step-by-Step Process

Answer Box: How to Get Chenodal (Chenodiol) Covered by UnitedHealthcare in Ohio

UnitedHealthcare covers Chenodal (chenodiol) for radiolucent gallstones when surgery is contraindicated, requiring prior authorization through OptumRx. Key requirements: documented ursodiol failure (6+ months), imaging confirming radiolucent stones, normal liver function tests, and gastroenterologist prescription. Submit PA via UHC Provider Portal with complete documentation. If denied, Ohio allows two internal appeals plus external review through an Independent Review Organization within 180 days. First step today: gather imaging reports confirming radiolucent stones and ursodiol trial records.

Table of Contents

Who Should Use This Guide

This guide helps Ohio patients and their healthcare providers navigate UnitedHealthcare's prior authorization process for Chenodal (chenodiol). You'll benefit most if you have:

  • Radiolucent gallstones confirmed by imaging
  • High surgical risk due to age or medical conditions
  • Failed or can't tolerate ursodiol (the first-line treatment)
  • A UnitedHealthcare plan (commercial, Medicare Advantage, or Medicaid managed care)

Expected outcome: With proper documentation, approval rates improve significantly. Ohio's external review process provides an additional safety net if your initial request is denied.

Member & Plan Basics

Coverage Verification

Before starting, confirm your UnitedHealthcare plan details:

  • Active coverage through your member portal or ID card
  • Pharmacy benefit managed by OptumRx (most UHC plans)
  • Deductible status and specialty tier copays
  • Prior authorization requirements for specialty medications
Tip: Call UnitedHealthcare member services at 1-866-441-2422 to verify Chenodal requires prior authorization under your specific plan.

Plan Types in Ohio

UnitedHealthcare operates several plan types in Ohio:

  • Commercial plans (employer-sponsored)
  • Medicare Advantage (UnitedHealthcare AARP plans)
  • Medicaid managed care (MyCare Ohio for dual-eligible members)
  • Marketplace plans (healthcare.gov)

Each has slightly different appeal timelines and processes, though the basic PA requirements remain consistent.

Clinical Criteria for Coverage

UnitedHealthcare covers Chenodal when all these criteria are met:

Primary Indication

  • Radiolucent cholesterol gallstones in a well-opacifying gallbladder
  • Not a surgical candidate due to age or systemic disease
  • No complications (cholecystitis, cholangitis, obstruction, pancreatitis)

Step Therapy Requirement

Effective April 1, 2025, UnitedHealthcare requires:

  • 6-month ursodiol trial at 8-10 mg/kg/day with documented failure OR
  • Ursodiol contraindication with clinical justification

Imaging Requirements

  • Recent imaging (within 6 months) confirming radiolucent stones
  • Well-visualizing gallbladder on contrast studies
  • Stone characteristics: typically <15mm, floating type preferred

Laboratory Requirements

  • Normal liver function tests within 3 months (ALT, AST, bilirubin, alkaline phosphatase)
  • No preexisting hepatic impairment
  • Pregnancy test (if applicable) - Chenodal is contraindicated in pregnancy

Required Documentation

For Initial Prior Authorization

Gather these documents before submitting:

Clinical Documentation:

  • Gastroenterologist consultation note
  • Imaging reports (ultrasound/CT) confirming radiolucent stones
  • Laboratory results (LFTs within 3 months)
  • Ursodiol trial documentation (dates, dosing, reason for discontinuation)

Administrative Items:

  • Complete prior authorization form
  • Patient weight and calculated dose
  • ICD-10 code: K80.20 (calculus of gallbladder without cholecystitis)

Medical Necessity Letter Components

Your provider's letter should include:

  1. Patient demographics and UHC member ID
  2. Diagnosis with ICD-10 code K80.20
  3. Imaging findings with specific mention of "radiolucent" stones
  4. Surgical contraindication details
  5. Ursodiol trial history (exact dates and outcomes)
  6. Proposed dosing (13-16 mg/kg/day based on ideal body weight)
  7. Monitoring plan (monthly LFTs initially, then every 6 months)

Step-by-Step: Fastest Path to Approval

1. Verify Eligibility (Patient/Clinic)

  • Confirm active UnitedHealthcare coverage
  • Check that OptumRx manages pharmacy benefits
  • Timeline: Same day
  • Source: UHC Member Portal

2. Gather Required Documentation (Clinic)

  • Obtain imaging reports confirming radiolucent stones
  • Document ursodiol trial or contraindication
  • Get recent LFTs (within 3 months)
  • Timeline: 1-3 business days
  • Source: Medical records department

3. Complete Prior Authorization (Provider)

  • Submit via UHC Provider Portal
  • Include all required documentation
  • Timeline: Submit within 7 days of prescription
  • Expected response: 72 hours for standard review

4. Monitor Status (Patient/Clinic)

  • Check portal for updates
  • Record confirmation numbers
  • Timeline: Daily until decision
  • Source: UHC Provider Portal status tracker

5. If Approved: Specialty Pharmacy Coordination

  • OptumRx coordinates with preferred specialty pharmacies
  • Verify shipment details and delivery timeline
  • Timeline: 3-5 business days from approval

6. If Denied: Internal Appeal (within 180 days)

  • File appeal with additional documentation
  • Request peer-to-peer review if available
  • Timeline: 30 days for standard appeal decision

7. External Review (if needed)

  • File with Ohio Department of Insurance within 180 days
  • Independent medical review by certified IRO
  • Timeline: 30 days for decision (72 hours if expedited)

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
Step therapy not met Provide ursodiol trial records Prescription dates, dosing, discontinuation reason
Not medically necessary Submit imaging showing radiolucent stones Ultrasound/CT explicitly stating "radiolucent"
Surgical candidate Get specialist note on surgical risk Anesthesia consult or comorbidity assessment
Missing labs Submit recent LFTs Results within 3 months showing normal function
Off-label use Clarify gallstone indication FDA labeling excerpt for gallstone dissolution

Appeals Process in Ohio

Internal Appeals with UnitedHealthcare

First Level Appeal:

  • Timeline: File within 180 days of denial
  • Decision time: 30 days (72 hours if expedited)
  • How to file: UHC Provider Portal or member portal
  • Required: Original denial letter, additional clinical documentation

Second Level Appeal (if available):

  • Timeline: 30 days from first-level denial
  • Process: Same as first level with independent reviewer

Ohio External Review

After exhausting internal appeals, Ohio residents can request external review:

Eligibility:

Process:

  1. Submit written request to UnitedHealthcare (not ODI directly)
  2. UHC forwards to Ohio-certified Independent Review Organization
  3. Submit additional info to IRO within 10 business days
  4. IRO decision within 30 days (binding on UnitedHealthcare)

Expedited Review:

  • Available when delay would seriously jeopardize health
  • Requires physician certification
  • Decision within 72 hours
From our advocates: We've seen UnitedHealthcare approvals improve dramatically when the medical necessity letter specifically states "radiolucent cholesterol gallstones confirmed by imaging" rather than generic "gallstones." This precise language aligns with their coverage policy and reduces back-and-forth requests for clarification.

Medical Necessity Letter Template

[Date]

UnitedHealthcare Prior Authorization Department
OptumRx

Re: Prior Authorization Request - Chenodal (chenodiol)
Member: [Name, DOB, Member ID]
Provider: [Name, NPI]

Clinical Summary:
Patient is a [age]-year-old with symptomatic radiolucent cholesterol gallstones (ICD-10: K80.20) confirmed by [ultrasound/CT] on [date]. Imaging demonstrates [size/number] radiolucent stones in a well-opacifying gallbladder. Patient is not a surgical candidate due to [specific contraindications - age, cardiac risk, etc.].

Prior Therapy:
Patient failed/was intolerant to ursodiol [dose] from [start date] to [end date] due to [specific reason - inadequate response, GI intolerance, etc.]. [Include specific details about trial duration and outcome.]

Current Request:
Requesting Chenodal (chenodiol) [dose] mg twice daily (total daily dose [X] mg, calculated at [X] mg/kg based on ideal body weight of [X] kg).

Supporting Laboratory Data:
Recent liver function tests ([date]): ALT [value], AST [value], total bilirubin [value], alkaline phosphatase [value] - all within normal limits.

Monitoring Plan:
Monthly LFTs for first 3 months, then every 6 months. Follow-up imaging at 6-12 months to assess stone dissolution.

Clinical Justification:
Chenodal is FDA-approved for dissolving radiolucent gallstones in patients who are poor surgical candidates. Given patient's surgical contraindications and ursodiol failure, chenodiol represents the appropriate next-line therapy per FDA labeling.

Sincerely,
[Provider signature and credentials]

Costs & Patient Support

Manufacturer Support

Travere Therapeutics Patient Support:

  • Enrollment forms available for copay assistance
  • Prior authorization support through specialty pharmacy partners
  • Contact: (verify current number with manufacturer website)

Ohio-Specific Resources

  • Ohio Department of Insurance Consumer Hotline: 1-800-686-1526
  • OSHIIP (for Medicare-related questions): Ohio Senior Health Insurance Information Program
  • UHCAN Ohio: Universal Health Care Action Network for consumer advocacy

When to Escalate

Contact Ohio Department of Insurance If:

  • UnitedHealthcare improperly denies external review eligibility
  • Appeal deadlines aren't honored
  • You need help understanding your rights

Ohio Department of Insurance
Consumer Services Division
Phone: 1-800-686-1526
Website: insurance.ohio.gov

File a Regulatory Complaint For:

  • Pattern of inappropriate denials
  • Failure to follow Ohio external review requirements
  • Procedural violations in appeals process

FAQ

How long does UnitedHealthcare prior authorization take for Chenodal in Ohio?
Standard review: 72 hours. Expedited review (if medically urgent): 24 hours. Submit complete documentation to avoid delays.

What if Chenodal is non-formulary on my UnitedHealthcare plan?
Non-formulary drugs require medical exception requests. Emphasize lack of formulary alternatives for radiolucent gallstone dissolution after ursodiol failure.

Can I request an expedited appeal in Ohio?
Yes, if delay would seriously jeopardize your health. Requires physician certification. Both internal appeals and external review offer expedited options.

Does the ursodiol step therapy requirement apply if I tried it in another state?
Yes, documented ursodiol trials from other states count toward UnitedHealthcare's step therapy requirement. Ensure records clearly show trial duration and outcome.

What's the cost difference between internal and external appeals?
Both are free to patients. Ohio's external review is funded by insurer fees, not patient charges.

How do I know if my UnitedHealthcare plan is subject to Ohio external review?
State-regulated plans (individual, small group, fully insured large group) use Ohio's process. Self-funded employer plans follow federal ERISA rules but may voluntarily use similar processes.

About Counterforce Health

Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by analyzing denial letters, plan policies, and clinical notes to create targeted, evidence-backed rebuttals. The platform identifies specific denial reasons and drafts point-by-point responses aligned to each plan's own coverage rules, significantly improving approval rates for complex medications like Chenodal.

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage policies change frequently. Always verify current requirements with UnitedHealthcare and consult your healthcare provider for medical decisions. For questions about your rights under Ohio insurance law, contact the Ohio Department of Insurance at 1-800-686-1526.

Sources & Further Reading

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