By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by Cigna in New Jersey: Complete PA Guide with IHCAP Appeals

Answer Box: Chenodal Coverage with Cigna in New Jersey

Cigna requires prior authorization for Chenodal (chenodiol) with specific imaging documentation proving radiolucent gallstones and surgical ineligibility. Submit PA request with ultrasound reports, KUB/CT showing radiolucent stones, and medical justification for surgical risk. If denied, appeal within 180 days through Cigna's internal process, then file external review with New Jersey's IHCAP program via Maximus Federal Services within 120 days of final denial.

First step today: Contact your prescriber to gather imaging documentation and complete Cigna's PA form with surgical contraindication details.

Table of Contents

  1. Coverage Requirements at a Glance
  2. Step-by-Step: Fastest Path to Approval
  3. Required Imaging Documentation
  4. Common Denial Reasons & How to Fix Them
  5. Appeals Process: Cigna Internal to New Jersey External Review
  6. Medical Necessity Letter Checklist
  7. New Jersey IHCAP External Review Process
  8. Costs and Patient Support Options
  9. FAQ: Common Questions

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required before dispensing Cigna member portal or provider line Cigna PA Policy
Age Requirement 18+ years old Clinical documentation FDA Label
Imaging Documentation Ultrasound + KUB/CT proving radiolucent stones Radiology reports Cigna Coverage Policy
Prior Therapy Ursodiol trial OR surgical contraindication Medical records Cigna PA Requirements
Approval Duration 12 months maximum PA determination letter Cigna Policy
Appeals Deadline 180 days from denial Cigna appeals notice Cigna Appeals Process

Step-by-Step: Fastest Path to Approval

1. Gather Required Imaging (Patient + Clinic)

Timeline: 1-2 weeks

  • Request ultrasound report confirming gallstones and normal gallbladder function
  • Obtain KUB or CT scan demonstrating radiolucent (non-calcified) stones
  • Ensure reports state gallbladder "opacifies well" or functions normally

2. Document Prior Therapy or Surgical Risk (Prescriber)

Timeline: 2-3 days

  • Medical records showing 6-month ursodiol trial with inadequate response, OR
  • Detailed documentation of surgical contraindications (age, comorbidities, anesthesia risk)
  • Baseline liver function tests (ALT/AST, bilirubin)

3. Complete Cigna PA Form (Prescriber)

Timeline: 1 business day

  • Submit via Cigna provider portal or fax
  • Include clinical justification addressing PA criteria
  • Attach all supporting documentation

4. Submit Complete Package

Timeline: Same day

  • Cigna processes complete requests in 2 business days
  • Incomplete requests may take 5-7 business days
  • Track status through provider portal or member services

5. Receive Determination

Timeline: 2-7 business days

  • If approved: Patient contacts Accredo specialty pharmacy to fill
  • If denied: Review denial reason and prepare appeal within 180 days
Tip: Submit requests early in the week to avoid weekend processing delays.

Required Imaging Documentation

Cigna mandates specific imaging to prove Chenodal candidacy:

Ultrasound Requirements

  • Confirmation of gallstones present
  • Documentation that gallbladder visualizes normally
  • Statement that gallbladder "opacifies well" or functions appropriately

Radiolucent Stone Confirmation

  • KUB (kidney-ureter-bladder) X-ray OR CT scan showing stones are NOT visible (radiolucent)
  • This proves stones are cholesterol-based, not calcified
  • Calcified or pigment stones will not dissolve with Chenodal
Note: Radiopaque (visible on X-ray) stones are an absolute contraindication for bile acid therapy.

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn Required Documentation
"No prior ursodiol trial" Submit medical records showing 6-month trial with inadequate response Prescription history, progress notes, imaging showing persistent stones
"Surgical candidate" Provide detailed surgical risk assessment Anesthesia consultation, cardiac clearance showing high risk, age-related factors
"Stones not confirmed radiolucent" Submit KUB or CT demonstrating stones invisible on X-ray Radiology report explicitly stating "radiolucent" or "not visible on plain films"
"Off-label use without compendia support" Clarify on-label use for gallstone dissolution FDA prescribing information highlighting approved indication
"Quantity exceeds limits" Justify dosing based on weight-based recommendations Clinical notes showing 13-16 mg/kg/day dosing rationale

Counterforce Health helps clinicians draft targeted appeals that address specific denial reasons with evidence-backed rebuttals aligned to each payer's own coverage policies.

Appeals Process: Cigna Internal to New Jersey External Review

Cigna Internal Appeals

Who can file: Patient, prescriber, or authorized representative
Deadline: 180 days from denial notice
Timeline: 30 days for medical necessity appeals, 60 days maximum for others

Required documents:

  • Original denial letter
  • Completed appeal request form
  • Additional clinical evidence supporting medical necessity
  • Prescriber letter addressing denial reasons

Submission: Mail to address on denial letter or submit via Cigna member portal

New Jersey IHCAP External Review

When eligible: After completing Cigna's internal appeal process
Deadline: 120 days from final internal denial
Administrator: Maximus Federal Services
Cost: Free to patients; insurer pays all costs

Timeline:

  • Preliminary review: 5 business days to accept/reject
  • Full review: 45 days for standard cases, 48 hours for expedited
  • Implementation: Health plan must comply within 10 business days if overturned

Medical Necessity Letter Checklist

For prescribers drafting appeals or PA requests:

Clinical Documentation Requirements

  • Patient age 18+ with symptomatic gallstone disease
  • Imaging confirmation of radiolucent cholesterol gallstones <15mm
  • Gallbladder visualization on ultrasound or oral cholecystography
  • Documentation of surgical risk factors or contraindications
  • Prior ursodiol trial with inadequate response (if applicable)
  • Baseline liver function tests within normal limits
  • Treatment goals and monitoring plan

Evidence to Include

  • FDA prescribing information for approved indication
  • Clinical trial data showing 13.5% complete dissolution at 750mg/day
  • Patient-specific factors supporting non-surgical management
  • Proposed dosing: 13-16 mg/kg/day (maximum studied efficacy)
From our advocates: When appealing imaging-related denials, we've found success highlighting the specific language from radiology reports that confirms "radiolucent" or "cholesterol-type" stones. Including a brief explanation of why surgical risk outweighs benefits often strengthens the medical necessity argument.

New Jersey IHCAP External Review Process

New Jersey's Independent Health Care Appeals Program provides binding external review through Maximus Federal Services when Cigna denies medically necessary treatments.

Eligibility Requirements

  • Completed Cigna's internal appeal process
  • Denial based on medical necessity, experimental/investigational determination
  • Filed within 120 days of final internal denial

Submission Process

Contact: IHCAP via Maximus or call 1-888-393-1062
Required documents:

  • Final Cigna denial letter
  • Complete medical records
  • IHCAP external review request form
  • Prescriber letter supporting medical necessity

Success Rate

External reviews favor consumers in approximately 50% of cases nationwide, with specialty drug appeals often successful when proper clinical evidence is provided.

Costs and Patient Support Options

Manufacturer Support

Travere Therapeutics offers patient assistance programs (verify current eligibility at manufacturer website)

Specialty Pharmacy

Accredo manages Cigna specialty drug fulfillment and may offer copay assistance programs

State Resources

New Jersey Department of Banking and Insurance
Consumer Hotline: 1-800-446-7467
IHCAP Information: 1-888-393-1062

FAQ: Common Questions

How long does Cigna PA take in New Jersey?
Standard requests: 2-3 business days for complete submissions. Expedited requests (urgent medical need): 24 hours.

What if Chenodal is non-formulary on my plan?
Request formulary exception through Cigna's standard PA process. Include clinical justification for why formulary alternatives are inappropriate.

Can I request expedited appeal if my condition worsens?
Yes. If delay would seriously jeopardize health, request expedited review. Both Cigna internal appeals and IHCAP external reviews offer expedited timelines.

Does step therapy apply if I failed ursodiol outside New Jersey?
Medical records from any state showing adequate ursodiol trial should satisfy step therapy requirements. Include complete prescription and progress note documentation.

What happens if IHCAP overturns Cigna's denial?
The decision is binding. Cigna must provide coverage and submit implementation report within 10 business days.

Can my doctor file the IHCAP appeal for me?
Yes. Providers can file external appeals on behalf of patients with proper consent forms.

For complex appeals involving multiple denial reasons or unusual clinical circumstances, Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing the specific denial basis and drafting point-by-point rebuttals aligned to each payer's coverage policies.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions vary by individual plan and clinical circumstances. Consult your healthcare provider and insurance plan documents for specific guidance. For assistance with New Jersey insurance appeals, contact the Department of Banking and Insurance Consumer Hotline at 1-800-446-7467.

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