By Counterforce Health Team in Chenodal (chenodiol) —

How to Get Chenodal (Chenodiol) Covered by UnitedHealthcare in New York: Complete Guide with Forms, Appeals, and Step-by-Step Process

Answer Box: Getting Chenodal (Chenodiol) Covered by UnitedHealthcare in New York

Current Coverage Status: UnitedHealthcare requires prior authorization for Chenodal (chenodiol) but coverage is now restricted to cerebrotendinous xanthomatosis (CTX) only. Gallstone dissolution is no longer a covered indication.

Fastest Path to Approval:

  1. Confirm CTX diagnosis with genetic testing showing CYP27A1 variants
  2. Submit PA via UnitedHealthcare Provider Portal with specialist documentation
  3. If denied, file internal appeal within 180 days, then external review through New York DFS

First Step Today: Call UnitedHealthcare member services at the number on your ID card to confirm your plan's current formulary status for Chenodiol and PA requirements.

Table of Contents

  1. Coverage Basics
  2. Prior Authorization Process
  3. Medical Necessity Criteria
  4. Step-by-Step: Fastest Path to Approval
  5. Common Denial Reasons & Solutions
  6. Appeals Process in New York
  7. Costs and Financial Assistance
  8. Specialty Pharmacy Requirements
  9. When to Escalate and Get Help
  10. FAQ: Most Common Questions

Coverage Basics

Is Chenodal Covered by UnitedHealthcare?

Limited coverage: UnitedHealthcare covers Chenodal (chenodiol) only for cerebrotendinous xanthomatosis (CTX), a rare genetic disorder. Coverage for gallstone dissolution has been discontinued across most UnitedHealthcare plans.

Which UnitedHealthcare Plans Are Affected?

  • Commercial plans: Employer-sponsored and individual market plans
  • Medicare Advantage: UnitedHealthcare MAPD plans in New York
  • Medicaid managed care: Plans administered by UnitedHealthcare

All require prior authorization through OptumRx specialty pharmacy services.

Note: Formulary placement varies by plan. Chenodal typically appears on Tier 3 (non-preferred brand) or Tier 5 (specialty) with significant cost-sharing.

Prior Authorization Process

Who Submits the Prior Authorization?

Your prescribing physician must submit the PA request. Patients cannot submit directly, but you can help gather required documentation.

How to Submit

Primary method: UnitedHealthcare Provider Portal

  • Login required for healthcare providers
  • Navigate to "Prior Authorization" section
  • Select "Specialty Pharmacy" for Chenodal

Alternative: Phone submission at 1-800-711-4555 (OptumRx Prior Authorization Department)

Expected Timeline

  • Standard review: 15 business days
  • Expedited review: 24-72 hours (requires urgent medical need documentation)
  • Incomplete submissions: Additional 14 days after missing information provided

Medical Necessity Criteria

Covered Indication: Cerebrotendinous Xanthomatosis (CTX) Only

UnitedHealthcare requires all of the following for approval:

Requirement Documentation Needed Source
Genetic confirmation Lab report showing pathogenic CYP27A1 variants OptumRx PA Policy
Specialist prescriber Endocrinologist, neurologist, or geneticist UnitedHealthcare Medical Policy
Clinical diagnosis CTX symptoms (diarrhea, cataracts, xanthomas, neurologic issues) FDA Prescribing Information
Treatment rationale Why alternatives are inappropriate Provider documentation

No Longer Covered: Gallstone Dissolution

Important: UnitedHealthcare has removed coverage for:

  • Radiolucent cholesterol gallstones
  • Gallstone dissolution therapy
  • Any gallbladder-related indications

Even with imaging showing radiolucent stones, PA requests for gallstone treatment will be denied.

Step-by-Step: Fastest Path to Approval

Step 1: Confirm Diagnosis and Prescriber

  • Patient action: Ensure you're seeing an endocrinologist, neurologist, or geneticist
  • Required: Genetic testing confirming CTX with CYP27A1 variants
  • Timeline: Allow 2-4 weeks for genetic test results

Step 2: Gather Required Documentation

  • Genetic test report showing pathogenic variants
  • Specialist consultation note with CTX diagnosis
  • Clinical rationale for Chenodal therapy
  • Previous treatment history (if any)

Step 3: Provider Submits PA Request

  • Method: UnitedHealthcare Provider Portal
  • Who: Prescribing specialist
  • Include: All documentation from Step 2
  • Timeline: Submit within 30 days of prescription

Step 4: Monitor PA Status

  • Provider: Check portal for updates
  • Patient: Call member services for status updates
  • Follow up: If no response in 15 business days

Step 5: If Approved - Specialty Pharmacy Setup

  • Automatic: Prescription routed to UnitedHealthcare-contracted specialty pharmacy
  • Patient: Expect call from pharmacy within 24-48 hours
  • Setup: Delivery and monitoring services

Step 6: If Denied - Begin Appeal Process

  • Timeline: 180 days from denial notice
  • First: Internal appeal with UnitedHealthcare
  • Second: External review through New York DFS

Step 7: Ongoing Management

  • Reauthorization: Required annually
  • Monitoring: Specialist follow-up and lab work
  • Documentation: Maintain records of clinical response

Common Denial Reasons & Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Submit genetic confirmation and specialist note CYP27A1 test results, CTX diagnosis
"Wrong indication" Clarify CTX diagnosis, not gallstones Specialist letter confirming CTX
"Non-specialist prescriber" Transfer to endocrinologist/neurologist/geneticist New prescription from specialist
"Insufficient documentation" Provide complete clinical picture All required forms and test results
"Experimental/investigational" Cite FDA approval for CTX FDA prescribing information

Appeals Process in New York

Internal Appeal with UnitedHealthcare

Timeline: Must file within 180 days of denial notice

How to file:

  • Online: UnitedHealthcare member portal
  • Phone: Member services number on ID card
  • Mail: Address provided in denial letter

Required documents:

  • Denial letter
  • Additional medical records
  • Updated provider letter
  • Any new clinical evidence

External Review Through New York DFS

If internal appeal is denied, New York residents can request external review through the Department of Financial Services.

Timeline: 4 months from final internal denial

How to file:

  • Online: DFS External Appeal Portal
  • Phone: (888) 990-3991 for expedited cases
  • Mail: NYS DFS, 99 Washington Avenue, Box 177, Albany, NY 12210

Expedited review: Available for urgent medical needs (72-hour decision)

Tip: New York's external appeal database is searchable. Look up previous Chenodal decisions to strengthen your appeal with cited medical literature.

Costs and Financial Assistance

UnitedHealthcare Cost-Sharing

Typical costs (varies by plan):

  • Tier 3 (non-preferred brand): $50-150 copay or 25-40% coinsurance
  • Tier 5 (specialty): $100-300 copay or 25-50% coinsurance
  • Deductible: May apply before copay/coinsurance

Financial Assistance Options

Manufacturer support: Contact Travere Therapeutics patient services Foundation grants: Check with National Organization for Rare Disorders (NORD) State programs: New York residents may qualify for Essential Plan or Medicaid

For help applying: Call Community Health Advocates at 1-888-614-5400

Specialty Pharmacy Requirements

Why Specialty Pharmacy is Required

Chenodal requires:

  • Special handling and storage
  • Patient monitoring and support
  • Coordination with prescribing specialist

UnitedHealthcare-Contracted Pharmacies

Once PA is approved, your prescription will be transferred to a UnitedHealthcare-contracted specialty pharmacy. You cannot fill at retail pharmacies.

Process:

  1. Pharmacy contacts you within 24-48 hours
  2. Verify insurance and shipping information
  3. Schedule delivery (usually monthly)
  4. Coordinate refills and monitoring

When to Escalate and Get Help

Free Help in New York

Community Health Advocates: 1-888-614-5400

  • Free insurance appeal assistance
  • Help with PA paperwork
  • Guidance on New York appeal rights

New York Department of Financial Services: (800) 400-8882

  • External appeal questions
  • Insurance complaint filing
  • Consumer protection assistance

When to Contact Your State Representative

If you experience:

  • Repeated denials despite meeting criteria
  • Delays beyond published timelines
  • Lack of response from UnitedHealthcare
  • Urgent medical need with access barriers

Contact your New York Assembly member or State Senator for constituent services assistance.

FAQ: Most Common Questions

Q: How long does UnitedHealthcare prior authorization take for Chenodal? A: Standard review is 15 business days. Expedited review (for urgent cases) is 24-72 hours.

Q: What if Chenodal is not on my UnitedHealthcare formulary? A: Request a formulary exception with strong medical necessity documentation. If denied, appeal through New York's external review process.

Q: Can I get Chenodal covered for gallstone treatment? A: No. UnitedHealthcare no longer covers Chenodal for gallstone dissolution. Coverage is limited to CTX only.

Q: Do I need genetic testing to get Chenodal approved? A: Yes, for CTX indication. UnitedHealthcare requires genetic confirmation of pathogenic CYP27A1 variants.

Q: What if my doctor isn't a specialist? A: Transfer care to an endocrinologist, neurologist, or geneticist. UnitedHealthcare requires specialist prescribing for Chenodal.

Q: How much will Chenodal cost with UnitedHealthcare? A: Costs vary by plan, but expect $100-300+ monthly depending on your formulary tier and cost-sharing structure.

Q: Can I request an expedited appeal in New York? A: Yes, if delay would seriously jeopardize your health. Both UnitedHealthcare and New York DFS offer expedited review processes.

Q: What happens if my appeal is denied? A: After internal appeals are exhausted, you can request external review through New York DFS. Their decision is binding on UnitedHealthcare.

From our advocates: We've seen CTX patients successfully obtain Chenodal coverage by ensuring their genetic testing clearly shows pathogenic variants and working with specialists who understand the PA requirements. The key is complete documentation upfront – incomplete submissions often lead to unnecessary delays and denials.

How Counterforce Health Can Help

Counterforce Health specializes in turning insurance denials into successful appeals for complex medications like Chenodal. Our platform analyzes denial letters, identifies the specific coverage criteria, and creates evidence-backed appeals tailored to your insurer's requirements. For patients navigating UnitedHealthcare's prior authorization process, we help ensure all documentation meets their medical necessity standards and appeal deadlines.

If you're facing a Chenodal denial or need help with the prior authorization process, Counterforce Health can streamline the appeals process and improve your chances of approval.

Sources & Further Reading

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 personalized assistance with insurance appeals in New York, contact Community Health Advocates at 1-888-614-5400.

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