By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (chenodiol) Covered by Cigna in Georgia: Complete Appeals Guide with Forms and Deadlines

Answer Box: Getting Chenodal (chenodiol) Covered by Cigna in Georgia

Fastest path to approval: Have your gastroenterologist submit a prior authorization request through Cigna's provider portal with imaging confirming radiolucent gallstones, documentation that you're not a surgical candidate, and proof of failed/contraindicated ursodiol therapy. Cigna must respond within 2 business days for standard requests. If denied, file an internal appeal within 180 days, then request external review through Georgia DOI within 60 days of final denial. Start today: Call your prescriber to initiate the PA request and gather required documentation.

Table of Contents

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for all Chenodal prescriptions Cigna Provider Portal
Diagnosis Radiolucent gallstones in well-opacifying gallbladder FDA prescribing information
Age Restriction 18 years or older Payer policy requirements
Prescriber Specialty Gastroenterologist or qualified specialist Most payer policies
Surgical Contraindication Must document why cholecystectomy isn't appropriate Provider attestation required
Step Therapy Failed/contraindicated ursodiol trial required Prior therapy documentation
Quantity Limits Maximum 16 mg/kg/day, up to 24 months FDA dosing guidelines
Appeals Deadline 180 days for internal, 60 days for external review Georgia DOI regulations

Step-by-Step: Fastest Path to Approval

1. Gather Required Documentation

Who does it: You and your clinic
Timeline: 1-2 days

  • Insurance card and member ID
  • Imaging studies confirming radiolucent gallstones
  • Documentation of surgical contraindications (age, comorbidities, risk factors)
  • Records of ursodiol trial failure or contraindications
  • Current liver function tests

2. Prescriber Submits Prior Authorization

Who does it: Your gastroenterologist's office
Timeline: Same day

  • Submit through Cigna provider portal or call 1-800-882-4462
  • Include completed PA form with all clinical documentation
  • Request expedited review if medically urgent (24-hour response)

3. Cigna Reviews Request

Who does it: Cigna medical reviewers
Timeline: 2 business days (standard) or 24 hours (expedited)

  • Medical necessity evaluation against coverage criteria
  • Verification of step therapy requirements
  • Assessment of prescriber qualifications

4. Receive Determination

Who does it: Cigna notifies patient and prescriber
Timeline: Within review timeframe

  • If approved: Prescription can be filled at specialty pharmacy
  • If denied: Denial letter explains specific reasons and appeal rights

5. File Internal Appeal (if denied)

Who does it: Patient or prescriber
Timeline: Must file within 180 days of denial

  • Submit additional clinical evidence addressing denial reasons
  • Include peer-reviewed literature supporting medical necessity
  • Request peer-to-peer review with Cigna medical director

6. External Review (if internal appeal fails)

Who does it: Patient files with Georgia DOI
Timeline: Must file within 60 days of final denial

  • Contact Georgia DOI Consumer Services at 1-800-656-2298
  • Submit external review application with all documentation
  • Independent medical review binding on Cigna

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
"Not medically necessary" Submit detailed letter explaining why surgery isn't appropriate, include comorbidity documentation
"Step therapy not met" Provide records of ursodiol trial failure, intolerance, or contraindications
"Lack of imaging documentation" Submit ultrasound or CT scan confirming radiolucent gallstones
"Prescriber not qualified" Transfer prescription to gastroenterologist or hepatologist
"Exceeds quantity limits" Justify dosing based on patient weight and FDA guidelines
"Investigational use" Confirm prescription is for FDA-approved indication (gallstone dissolution)

Appeals Playbook for Cigna in Georgia

Internal Appeals Process

First-Level Internal Appeal

  • Deadline: 180 days from denial date
  • Review time: 30 days (standard) or 72 hours (expedited)
  • How to submit: Mail to Cigna National Appeals Unit, P.O. Box 188011, Chattanooga, TN 37422
  • Required documents: Denial letter, medical records, prescriber letter

Second-Level Internal Appeal

  • Automatic: Proceeds if first level denied
  • Review time: Additional 30 days
  • Reviewer: Different medical director than first level

External Review Through Georgia DOI

When eligible: After exhausting internal appeals for medical necessity denials Deadline: 60 days from final internal denial Cost: Free to patient How to file: Call 1-800-656-2298 or submit application online Decision timeline: 30 days (standard) or 72 hours (expedited) Binding: Yes, Cigna must comply with approval decisions

From our advocates: "We've seen Chenodal appeals succeed when prescribers clearly document why the patient isn't a surgical candidate and provide detailed records of ursodiol failure. One case involved a 78-year-old with multiple comorbidities where the appeal was approved after the gastroenterologist submitted a comprehensive letter explaining surgical risks and prior medication intolerance."

Medical Necessity Letter Checklist

Your prescriber's medical necessity letter should include:

Patient Information

  • Age and relevant comorbidities
  • Diagnosis with ICD-10 codes
  • Imaging results confirming gallstone type

Clinical Rationale

  • Why cholecystectomy is contraindicated or high-risk
  • Documentation of ursodiol trial (dates, duration, outcome)
  • Expected treatment goals and monitoring plan

Supporting Evidence

  • FDA prescribing information references
  • Relevant clinical guidelines
  • Peer-reviewed literature on efficacy

Treatment Plan

  • Proposed dosing (mg/kg/day calculation)
  • Duration of therapy (typically 6-24 months)
  • Liver function monitoring schedule

At Counterforce Health, we help patients and providers navigate complex prior authorization requirements by analyzing denial letters and crafting targeted appeals with the right clinical evidence and payer-specific language.

When to Request External Review

Consider external review through Georgia DOI if:

  • Cigna denied your internal appeal for medical necessity reasons
  • You have strong clinical evidence supporting Chenodal use
  • Your case involves FDA-approved indications
  • You're within the 60-day deadline from final denial

Not eligible for external review:

  • Purely contractual exclusions (drug not covered by plan)
  • Self-funded employer plans (ERISA)
  • Issues resolved through internal appeals

Scripts for Common Situations

Calling Cigna About PA Status

"Hi, I'm calling to check the status of a prior authorization for Chenodal, generic name chenodiol. My member ID is [number]. The request was submitted by Dr. [name] on [date]. Can you tell me the current status and if any additional information is needed?"

Requesting Peer-to-Peer Review

"I'd like to request a peer-to-peer review for the denied prior authorization for Chenodal. The denial was dated [date] and the reference number is [number]. When can Dr. [name] speak with your medical director?"

Escalating to External Review

"I need to file an external review request with the Georgia Department of Insurance. My Cigna internal appeal was denied on [date]. Can you provide me with the external review application and confirm the 60-day deadline?"

Frequently Asked Questions

How long does Cigna prior authorization take in Georgia? Standard reviews take 2 business days; expedited reviews for urgent cases take 24 hours. Your prescriber can request expedited review if delay could jeopardize your health.

What if Chenodal isn't on Cigna's formulary? You can request a formulary exception with clinical justification. Your prescriber must explain why formulary alternatives aren't appropriate for your condition.

Can I appeal if I'm denied for step therapy? Yes, you can request a step therapy override by documenting previous ursodiol failure, intolerance, or contraindications with your prescriber.

Does Cigna cover off-label uses of Chenodal? Generally no, unless supported by recognized compendia. Coverage typically requires FDA-approved indications like gallstone dissolution.

What if I miss the appeal deadline? Contact Georgia DOI Consumer Services immediately at 1-800-656-2298. While deadlines are strict, they may provide guidance on available options.

How often are external reviews successful? Georgia doesn't publish specific success rates, but external reviews provide independent medical evaluation and can overturn insurer denials when clinical evidence supports medical necessity.

Can I get help with the appeals process? Yes, contact Georgia DOI Consumer Services at 1-800-656-2298 for assistance. Organizations like Counterforce Health also help patients navigate complex appeals.

What documents do I need for external review? Submit your denial letters, medical records, prescriber's medical necessity letter, and any supporting clinical literature or test results.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on your specific plan and medical circumstances. Always consult with your healthcare provider and insurance company for personalized guidance. For assistance with appeals in Georgia, contact the Department of Insurance Consumer Services at 1-800-656-2298.

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