By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by Cigna in Washington: Complete Prior Authorization and Appeals Guide

Answer Box: Getting Chenodal Covered by Cigna in Washington

Cigna requires prior authorization for Chenodal (chenodiol) with mandatory step therapy—you must try ursodiol for 6 months first unless contraindicated. Your gastroenterologist submits the PA request through Cigna's provider portal, and standard approval takes 2 business days. If denied, you have 180 days to appeal internally, then can request an external review through Washington's Independent Review Organization (IRO) system.

First step today: Contact your prescribing physician to document your ursodiol trial (or contraindications) and submit the Cigna prior authorization form with complete clinical justification.

Table of Contents

When Alternatives Make Sense

Before pursuing Chenodal (chenodiol), it's important to understand when alternatives might be more accessible through Cigna. The insurer's coverage criteria specifically require that patients try ursodiol first, making it the logical starting point for most gallstone dissolution cases.

Clinical considerations for alternatives include:

  • Ursodiol availability: Generally preferred on formularies with fewer restrictions
  • Safety profile: Lower hepatotoxicity risk compared to chenodiol
  • Monitoring requirements: Less intensive liver function monitoring needed
  • Pregnancy considerations: Ursodiol is Category B vs. chenodiol's Category X contraindication

Typical Alternatives to Chenodal

Primary Alternative: Ursodiol (Ursodeoxycholic Acid)

Mechanism: Like chenodiol, ursodiol reduces cholesterol saturation in bile to promote gallstone dissolution.

Cigna coverage: Typically covered with standard prior authorization for radiolucent gallstones in patients who aren't surgical candidates. Formulary placement varies by plan but generally has fewer restrictions than chenodiol.

Effectiveness: Clinical studies show 28-38% dissolution rates for any size stones, with up to 81% success in patients with small stones (<15mm) over two years.

Surgical Management

Standard of care: Laparoscopic cholecystectomy remains the gold standard for symptomatic gallstones.

When medical therapy isn't appropriate: Calcified stones, pigment stones, non-functioning gallbladder, or complications like acute cholecystitis.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all chenodiol prescriptions Cigna provider portal PA Policy
Step Therapy Must try ursodiol for 6+ months first Clinical documentation Coverage Criteria
Age Requirement Patient must be 18+ years old PA form PA Guidelines
Specialist Required Gastroenterologist must prescribe Provider credentials PA Policy
Specialty Pharmacy Must use Accredo or approved SP Cigna member services Formulary
Appeals Deadline 180 days from denial Washington state law RCW 48.43.535

Step-by-Step: Fastest Path to Approval

1. Document Ursodiol Trial (Patient/Provider)

Timeline: Before PA submission
Required: 6-month trial documentation or contraindication evidence
Submit via: Clinical notes to gastroenterologist

2. Gather Required Documentation (Provider)

Timeline: 1-2 days
Required: Imaging showing radiolucent stones, surgical risk assessment, ursodiol outcome
Submit via: Compile for PA form

3. Complete Prior Authorization Form (Gastroenterologist)

Timeline: Same day
Required: Cigna chenodiol PA form
Submit via: Cigna provider portal or fax

4. Await Initial Decision (Cigna)

Timeline: 2 business days (standard) or 24 hours (expedited)
Required: Complete documentation review
Source: Washington insurance law

5. Coordinate Specialty Pharmacy (If Approved)

Timeline: 1-3 days post-approval
Required: Prescription transfer to Accredo or approved specialty pharmacy
Submit via: Provider coordination with pharmacy

Exception Strategy: When to Request

Consider requesting a formulary exception when:

Step therapy doesn't apply:

  • Documented ursodiol allergy or hypersensitivity
  • Severe adverse reactions to ursodiol preventing adequate trial
  • Clinical contraindication to ursodiol therapy

Medical necessity is compelling:

  • Rapid stone growth despite ursodiol therapy
  • Unique patient factors making chenodiol specifically indicated
  • Published case reports supporting chenodiol over ursodiol for your situation
Clinician Corner: Medical necessity letters should include: (1) specific diagnosis with ICD-10 codes, (2) detailed ursodiol trial outcomes, (3) clinical rationale for chenodiol, (4) monitoring plan for hepatotoxicity, and (5) citations from FDA labeling or peer-reviewed literature supporting the switch.

Appeals Playbook for Washington

Internal Appeal Process

Deadline: 180 days from denial
Submit to: Cigna appeals department via provider portal
Required documents: Original PA, additional clinical evidence, medical necessity letter
Timeline: Same as initial review (2 business days standard)

External Review (IRO)

When to use: After internal appeal denial
Deadline: 180 days from final internal denial
Submit to: Washington Office of Insurance Commissioner or directly to Cigna
Timeline: 30 days standard, 72 hours expedited
Cost: Free to patient
Contact: Washington OIC Consumer Advocacy at 1-800-562-6900

Note: In Washington, if Cigna doesn't respond within statutory deadlines, the exception is automatically granted by law.

Switching Logistics and Coordination

Provider Coordination

Your gastroenterologist should:

  • Document the complete ursodiol trial with specific outcomes
  • Obtain baseline liver function tests before chenodiol initiation
  • Coordinate with specialty pharmacy for prescription transfer
  • Schedule monthly LFT monitoring for the first 3 months

Specialty Pharmacy Requirements

Counterforce Health helps patients navigate these complex specialty pharmacy requirements by automatically generating the right documentation and coordinating between providers, patients, and pharmacies to streamline approval processes.

Required steps:

  1. Prescription sent to Accredo or Cigna-approved specialty pharmacy
  2. Pharmacy benefit verification and copay calculation
  3. Patient enrollment in specialty pharmacy program
  4. Delivery coordination and adherence monitoring

Patient Monitoring

Month 1-3: Monthly liver function tests
Month 4+: Every 3-6 months LFT monitoring
Imaging: Ultrasound every 6 months to assess stone dissolution
Discontinuation criteria: Aminotransferases >3x upper limit of normal

Re-trying for Chenodal Later

If your initial request is denied, document these elements during your ursodiol trial to strengthen a future chenodiol request:

Clinical documentation:

  • Specific adverse reactions to ursodiol with dates and severity
  • Lack of stone dissolution on serial imaging
  • Progression of symptoms despite adequate ursodiol dosing
  • Contraindications that develop during ursodiol therapy

Enhanced evidence:

  • Peer-reviewed literature supporting chenodiol in your specific case
  • Specialist consultation notes recommending the switch
  • Quality of life impact documentation
  • Alternative surgical risk assessments

Common Denial Reasons & Fixes

Denial Reason How to Overturn
Insufficient ursodiol trial Submit detailed 6-month trial documentation with outcomes
Lack of imaging evidence Provide ultrasound or CT showing radiolucent stones
Missing surgical assessment Include surgical consultation documenting high operative risk
Non-specialist prescriber Transfer care to gastroenterologist for PA submission
Incomplete monitoring plan Detail hepatic monitoring protocol and follow-up schedule
From our advocates: We've seen cases where patients were initially denied because their ursodiol trial was only 4 months. When they extended to 6 months and documented continued stone growth, the appeal was successful. The key is thorough documentation of the trial period and clear evidence of failure or intolerance.

FAQ

How long does Cigna prior authorization take in Washington?
Standard review takes 2 business days; expedited review for urgent cases takes 24 hours. If Cigna doesn't respond within these timeframes, the request is automatically approved under Washington law.

What if chenodiol is non-formulary on my plan?
You can request a formulary exception through the same PA process. Your gastroenterologist must provide clinical justification for why formulary alternatives (like ursodiol) are inappropriate.

Can I request an expedited appeal?
Yes, if delay could jeopardize your health. Expedited appeals in Washington must be decided within 24 hours for initial requests and 72 hours for external reviews.

Does step therapy apply if I tried ursodiol in another state?
Yes, documented ursodiol trials from other providers/states count toward Cigna's step therapy requirement as long as the documentation is complete.

How much does chenodiol cost with Cigna coverage?
Costs vary by plan, but specialty tier copays typically range from $50-200+ per month. Manufacturer copay assistance may be available through Travere Therapeutics.

What happens if my external review is denied?
The IRO decision is binding on Cigna. If denied, you can contact the Washington Office of Insurance Commissioner for guidance on potential regulatory complaints or legal options.

For complex cases involving multiple denials or unique clinical circumstances, Counterforce Health specializes in turning insurance denials into successful appeals by generating evidence-backed, payer-specific documentation that addresses each plan's specific requirements and clinical criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes and does not constitute medical advice. Coverage decisions depend on your specific plan terms and clinical situation. Always consult with your healthcare provider and contact Cigna directly to verify current policies and procedures. For appeals assistance, contact the Washington Office of Insurance Commissioner at 1-800-562-6900.

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