By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Approved by Humana in Ohio: Complete Prior Authorization Guide

Quick Answer: Getting Chenodal (Chenodiol) Covered by Humana in Ohio

Fastest path to approval: Submit a prior authorization through CoverMyMeds or Humana's member portal with imaging confirming radiolucent gallstones, documentation that you're not a surgical candidate, and baseline liver function tests. If denied, you have 65 days to appeal and can request Ohio external review within 180 days. Start today: Verify your Humana plan type and check if Chenodal requires PA in your 2024 formulary.

Table of Contents

  1. What This Guide Covers
  2. Before You Start: Plan Verification
  3. Gather Required Documentation
  4. Submit Your Prior Authorization Request
  5. Follow-Up Timeline and Tips
  6. If You're Asked for More Information
  7. If Your Request is Denied
  8. Ohio External Review Process
  9. Renewal and Re-Authorization
  10. Quick Reference Checklist
  11. Frequently Asked Questions

What This Guide Covers

This guide helps Ohio patients and their healthcare providers navigate Humana's prior authorization process for Chenodal (chenodiol), an oral bile acid used to dissolve radiolucent gallstones. We'll walk through the specific forms, timelines, and appeal rights available in Ohio, including how to access the state's external review system if Humana denies coverage.

Chenodal is typically subject to prior authorization because it's a specialty medication with specific clinical criteria and requires ongoing liver monitoring. With the right documentation and approach, most medically appropriate requests get approved.

Before You Start: Plan Verification

Check Your Humana Plan Type

Your appeal rights and forms depend on which type of Humana coverage you have:

  • Medicare Advantage/Part D: Use Medicare drug coverage determination forms
  • Commercial (individual/small group): Use Ohio state-specific PA forms
  • Large employer plans: May be self-funded (ERISA) with different appeal rights
  • Medicaid: Use Humana Healthy Horizons Ohio-specific process

Call the number on your insurance card or check your member portal to confirm your plan type.

Verify Chenodal's Formulary Status

Check your plan's drug list to see if Chenodal requires:

  • PA (prior authorization): Most common
  • ST (step therapy): Must try ursodiol first
  • QL (quantity limits): Restrictions on supply
  • NF (non-formulary): Not covered without exception

Use Humana's formulary search tool with your ZIP code and plan details.

Gather Required Documentation

Clinical Requirements for Chenodal Coverage

Requirement Documentation Needed Why It Matters
Radiolucent gallstones Ultrasound report showing stones Only 15-20% of stones are visible on X-ray; most are radiolucent
Functioning gallbladder HIDA scan or ultrasound showing contraction Chenodiol won't work if gallbladder doesn't function
Surgical ineligibility Physician note explaining contraindications Standard of care is cholecystectomy when possible
Baseline liver function ALT, AST, total bilirubin within 30 days Chenodiol causes liver enzyme elevations in ~30% of patients

ICD-10 Codes to Include

  • K80.20: Calculus of gallbladder without cholecystitis without obstruction
  • K80.10: Calculus of gallbladder with chronic cholecystitis without obstruction
  • R10.11: Right upper quadrant pain (if symptomatic)

Medical Necessity Letter Checklist

Your prescriber should address:

  • Diagnosis: Symptomatic radiolucent gallstones confirmed by imaging
  • Prior treatments: Conservative management attempted; surgical evaluation completed
  • Contraindications to surgery: Specific medical reasons (cardiac risk, patient refusal after counseling)
  • Stone characteristics: Size, number, and composition suitable for medical dissolution
  • Monitoring plan: Schedule for liver function tests and follow-up imaging
Tip: Counterforce Health helps clinicians create targeted prior authorization letters by analyzing your specific denial reasons and payer policies, potentially saving weeks in the approval process.

Submit Your Prior Authorization Request

For Medicare Advantage/Part D Plans

  1. Electronic submission (preferred): Use CoverMyMeds selecting Humana and your specific plan
  2. Paper submission: Download the "Request for Medicare Prescription Drug Coverage Determination" from Humana's forms page
  3. Fax: Follow instructions on the form for your region

For Commercial Plans in Ohio

  1. Use the state-specific form: Download Humana's State-Specific Prior Authorization Request Form
  2. Fax to: 1-877-486-2621
  3. Questions: Call 1-800-555-2546

Required Attachments

  • Medical necessity letter from prescriber
  • Ultrasound or imaging reports
  • Recent liver function tests
  • Documentation of surgical consultation or contraindications
  • Previous treatment history (conservative management, other medications tried)

Follow-Up Timeline and Tips

Expected Decision Timeframes

Plan Type Standard Review Expedited Review
Medicare Part D 7 calendar days 72 hours
Commercial 15 business days 72 hours
Medicaid 14 calendar days 3 business days

When to Follow Up

  • Day 3: Confirm Humana received your submission
  • Day 7: Check status if no acknowledgment received
  • Day 10: Call if approaching deadline without decision
  • Day 14+: Request expedited review if clinically appropriate

Sample Follow-Up Script

"Hi, I'm calling to check the status of a prior authorization request for Chenodal submitted on [date]. The reference number is [if available]. My member ID is [ID number]. Can you tell me if additional information is needed and when I can expect a decision?"

If You're Asked for More Information

Common Requests and Responses

"Need more clinical documentation": Submit detailed progress notes showing symptom severity and impact on daily activities

"Try ursodiol first": Provide documentation of ursodiol failure, intolerance, or contraindication

"Unclear surgical candidacy": Include formal surgical consultation note or detailed medical contraindications

"Liver function concerns": Ensure recent normal ALT, AST, and bilirubin levels are included

Peer-to-Peer Review

If Humana requests a peer-to-peer call:

  • Schedule within their timeframe (usually 3-5 business days)
  • Have your prescriber prepare to discuss specific clinical rationale
  • Bring imaging reports and liver function results to the call
  • Follow up within 24 hours for the decision

If Your Request is Denied

Understanding Denial Codes

Common Denial Reason How to Address
"Not medically necessary" Submit additional clinical evidence and guidelines
"Step therapy required" Document ursodiol failure or contraindication
"Non-formulary" Request formulary exception with medical necessity
"Experimental/investigational" Cite FDA approval and established guidelines

First-Level Appeal Process

Medicare plans: You have 65 days from the denial notice to file a redetermination request

Commercial plans: You have 60 days from the denial notice to file an internal appeal

Use the same forms as initial requests but check the "appeal" box and attach:

  • Original denial letter
  • Additional medical evidence addressing denial reasons
  • Updated medical necessity letter

Ohio External Review Process

If Humana upholds their denial after internal appeals, Ohio residents have strong external review rights.

Eligibility for Ohio External Review

  • Must complete Humana's internal appeal process first (unless expedited review qualified)
  • Denial involves medical necessity or clinical judgment
  • Plan is state-regulated (not self-funded ERISA)
  • Request filed within 180 days of final denial

How to Request External Review

  1. Call Ohio Department of Insurance: 800-686-1526 for guidance and forms
  2. Email: [email protected]
  3. Technical questions: 614-644-0188

External Review Timeline

  • Standard review: ~30 days for decision
  • Expedited review: ~72 hours if delay would seriously jeopardize health
  • Cost: Free to you; Humana pays the Independent Review Organization

The IRO decision is binding on Humana - if they overturn the denial, Humana must provide coverage.

From our advocates: We've seen Ohio external reviews succeed when patients include peer-reviewed studies showing chenodiol's effectiveness for their specific stone characteristics, along with clear documentation of why surgery isn't appropriate. The key is addressing the exact medical necessity criteria the IRO will evaluate.

Renewal and Re-Authorization

When to Reapply

Chenodal authorizations typically last:

  • 6-12 months for initial approvals
  • 12 months for renewals with stable patients

Renewal Documentation

  • Follow-up imaging: Ultrasound showing stone dissolution progress
  • Updated liver function tests: Normal ALT, AST, and bilirubin
  • Clinical progress note: Symptom improvement and tolerance
  • Continued medical necessity: Why ongoing treatment is needed

Calendar your renewal request 30-45 days before expiration to avoid gaps in coverage.

Quick Reference Checklist

Before submitting:

  • Verify plan type and formulary status
  • Obtain recent ultrasound showing radiolucent stones
  • Get baseline liver function tests (ALT, AST, bilirubin)
  • Document surgical consultation or contraindications

Submit via:

  • CoverMyMeds (preferred) or Humana portal
  • Include medical necessity letter addressing all requirements
  • Attach all supporting documentation

Follow up:

  • Confirm receipt within 3 days
  • Check status at day 7 and 14
  • Request expedited review if clinically urgent

If denied:

  • File appeal within 60-65 days
  • Address specific denial reasons
  • Consider Ohio external review if final denial

Frequently Asked Questions

How long does Humana prior authorization take in Ohio? Standard reviews take 7 days for Medicare Part D and 15 business days for commercial plans. Expedited reviews are decided within 72 hours when delay could harm your health.

What if Chenodal is non-formulary on my plan? You can request a formulary exception by demonstrating medical necessity and that covered alternatives are inappropriate. Use the same PA forms but specify you're requesting an exception.

Can I get an expedited appeal? Yes, if your doctor certifies that waiting for a standard appeal timeline could seriously harm your health or ability to regain function. This reduces decision time to 72 hours.

Does step therapy apply if I haven't tried ursodiol? Many Humana plans require ursodiol trial first. However, you can bypass step therapy by documenting contraindications, previous failures, or clinical reasons why ursodiol isn't appropriate.

What happens if I move from Ohio during treatment? Your Humana coverage and prior authorization should continue, but appeal rights may change based on your new state's laws. Contact Humana member services to confirm continued coverage.

How often do I need liver monitoring on Chenodal? Chenodiol requires periodic liver function monitoring throughout treatment. Most providers check ALT, AST, and bilirubin every 1-3 months initially, then at least yearly.

When navigating complex prior authorization requirements, Counterforce Health provides specialized support to help patients and clinicians turn insurance denials into successful, evidence-backed appeals. Their platform analyzes your specific denial reasons and creates targeted responses aligned to your payer's policies.

Sources & Further Reading

Disclaimer: This guide provides general information about insurance processes and should not replace personalized medical advice. Always consult with your healthcare provider about treatment decisions. For specific questions about your Humana coverage, contact member services directly. Appeal deadlines and processes may change - verify current requirements with official sources.

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