By Counterforce Health Team in Dojolvi (triheptanoin) —

Denied for Dojolvi (Triheptanoin) by UnitedHealthcare in New Jersey? Complete Appeal Guide with Templates

Answer Box: UnitedHealthcare requires prior authorization for Dojolvi (triheptanoin) with molecular confirmation of long-chain fatty acid oxidation disorder (LC-FAOD) and specialist prescription. No step therapy applies. If denied, request peer-to-peer review immediately, then file internal appeal within 180 days. After exhausting internal appeals, use New Jersey's IHCAP external review (85% success rate for appeals). Start today: gather genetic test results and specialist documentation.

Table of Contents

Understanding Your Denial Letter

When UnitedHealthcare denies Dojolvi coverage, your denial letter will specify the exact reason and include critical deadlines. Look for these key elements:

Denial Reason Codes:

  • PA required: Prior authorization wasn't submitted or was incomplete
  • Medical necessity: Clinical criteria not met (most common for Dojolvi)
  • Non-formulary: Drug not on preferred list (rare for Dojolvi)
  • Quantity limits: Dosing exceeds policy maximums

Critical Deadlines:

  • Internal appeals: 180 days from denial date for most UnitedHealthcare plans
  • Expedited appeals: Available if delay could seriously harm health
  • External review: 4 months after final internal denial in New Jersey
Tip: Call UnitedHealthcare member services immediately to confirm your specific appeal deadline and process.

Fixable Causes Before Appealing

Many Dojolvi denials can be resolved without formal appeals:

Missing Documentation

  • Genetic test results showing pathogenic mutations in CPT2, ACADVL, HADHA, or HADHB genes
  • Specialist prescription from board-certified metabolic geneticist or endocrinologist
  • MCT discontinuation documentation with dates and clinical rationale

Coding Issues

  • Ensure prescription uses correct NDC codes for Dojolvi
  • Verify ICD-10 codes match your specific LC-FAOD diagnosis
  • Check that dosing doesn't exceed 35% of daily caloric intake

Benefit vs. Medical Policy

  • Confirm whether Dojolvi is covered under pharmacy or medical benefit
  • Some plans may require specialty pharmacy dispensing through OptumRx

UnitedHealthcare Prior Authorization Requirements

Based on UnitedHealthcare's official policy, Dojolvi approval requires:

Requirement Details Documentation Needed
Molecular Diagnosis Confirmed LC-FAOD by genetic testing Lab reports showing pathogenic mutations
Specialist Prescriber Board-certified metabolic geneticist Provider credentials and specialty certification
MCT Discontinuation No concurrent medium-chain triglyceride use Clinical notes documenting cessation
Dosage Limits ≤35% of total daily caloric intake Dietitian assessment and dosing calculations
Dietary Management Disease-specific nutritional plan Metabolic dietitian documentation

Good news: UnitedHealthcare does not require step therapy for Dojolvi, as it's the only FDA-approved therapy for LC-FAOD.

First-Level Internal Appeal Process

Step-by-Step Appeal Submission

  1. Gather Required Documents (Timeline: 1-2 days)
    • Original denial letter
    • Complete medical records
    • Genetic test results
    • Specialist letter of medical necessity
  2. Submit Appeal (Timeline: Same day)
    • Online: UnitedHealthcare member portal
    • Fax: Use number on denial letter
    • Mail: Address provided in denial notice
  3. Track Your Appeal (Timeline: Ongoing)
    • UnitedHealthcare must respond within 30 days (standard) or 72 hours (urgent)
    • Call member services weekly for status updates

Medical Necessity Letter Checklist

Your specialist should include:

  • Patient identification and LC-FAOD diagnosis with specific genetic mutation
  • Clinical history including prior hospitalizations, metabolic crises, or complications
  • Previous treatments tried and failed (MCT oil, dietary modifications)
  • Rationale for Dojolvi citing FDA approval and clinical guidelines
  • Dosing justification with caloric intake calculations
  • Monitoring plan and expected outcomes
Clinician Corner: Reference the FDA label for Dojolvi and cite peer-reviewed studies on triheptanoin efficacy in LC-FAOD when available.

Peer-to-Peer Review Strategy

Before filing a formal appeal, request a peer-to-peer review with UnitedHealthcare's medical director.

How to Schedule

  • Call UnitedHealthcare provider services
  • Request "peer-to-peer review for Dojolvi denial"
  • Typical scheduling: 3-5 business days

Preparation Checklist

  • Key talking points: FDA approval, lack of alternatives, patient's clinical history
  • Have ready: Genetic test results, prior treatment failures, current symptoms
  • Emphasize urgency: Risk of metabolic decompensation without treatment

Sample Script for Providers

"I'm calling to request a peer-to-peer review for [patient name] who was denied Dojolvi. This patient has molecularly confirmed LC-FAOD with [specific mutation] and has failed standard dietary management. Dojolvi is the only FDA-approved therapy for this condition, and delay could result in serious metabolic complications."

Second-Level & External Review in New Jersey

If your internal appeal fails, New Jersey offers excellent external review through the Independent Health Care Appeals Program (IHCAP).

New Jersey IHCAP Process

Managed by: Maximus Federal Services Timeline: 45 days for standard review, 48 hours for urgent cases Cost: Free to patients Success rate: Appeals have strong success rates when properly documented

How to File External Review

  1. Complete Internal Appeals first (required)
  2. Submit within 4 months of final denial
  3. File online at IHCAP portal or mail to address provided
  4. Include all documentation: Medical records, denial letters, specialist letters

Required Forms

  • IHCAP external appeal application
  • Copy of final internal appeal denial
  • All relevant medical records
  • Letter addressing each denial reason
Note: The IHCAP decision is binding on UnitedHealthcare and costs are borne by the insurer.

For questions, call Maximus IHCAP at 1-888-393-1062 or New Jersey DOBI at 1-800-446-7467.

Appeal Templates and Scripts

Patient Phone Script for UnitedHealthcare

"I'm calling about a denied prior authorization for Dojolvi for my [child/myself]. The denial reason was [specific reason from letter]. I have additional documentation from my specialist and would like to know the fastest way to submit an appeal. Can you also tell me about requesting a peer-to-peer review?"

Email Template for Medical Records Request

Subject: Urgent - Medical Records Needed for Insurance Appeal

"Dear [Clinic Name],

I need the following records for my insurance appeal for Dojolvi:

  • Genetic test results showing LC-FAOD diagnosis
  • All clinic notes from [specialist name]
  • Documentation of previous treatments tried
  • Current treatment plan and monitoring

Please send these within 48 hours to help meet my appeal deadline. Thank you."

Common Denial Reasons & Solutions

Denial Reason How to Overturn Required Documentation
Missing genetic confirmation Submit molecular testing results Lab report with pathogenic mutations identified
Concurrent MCT use Document discontinuation with dates Clinical notes showing MCT cessation and rationale
Non-specialist prescriber Transfer care or get co-signature Board certification in genetics/endocrinology
Exceeds quantity limits Justify dosing with caloric calculations Dietitian assessment showing medical necessity
"Experimental" classification Emphasize FDA approval FDA label and approval documentation

Cost Assistance Programs

While appealing, these programs can help with costs:

PAN Foundation

UltraCare Patient Services

State Programs

  • New Jersey pharmaceutical assistance programs may provide additional support
  • Contact NJ Department of Human Services for eligibility

When to Escalate to Regulators

If appeals fail or you face unreasonable delays:

New Jersey Department of Banking and Insurance

  • Consumer Hotline: 1-800-446-7467
  • File complaint: For violations of appeal timelines or procedures
  • Include: All correspondence, denial letters, appeal submissions

Federal Resources

  • CMS: For Medicare Advantage issues
  • Department of Labor: For employer-sponsored plans

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals for complex medications like Dojolvi. Our platform analyzes denial letters, identifies coverage criteria, and drafts point-by-point rebuttals using the right clinical evidence and payer-specific workflows. For patients and clinicians navigating prior authorization challenges, Counterforce Health provides the tools and expertise needed to secure coverage for life-saving therapies.

FAQ

How long does UnitedHealthcare prior authorization take for Dojolvi? Standard PA decisions: 15 business days. Urgent requests: 72 hours. Appeal responses: 30 days for internal, 45 days for external review in New Jersey.

What if Dojolvi isn't on UnitedHealthcare's formulary? Dojolvi is typically covered as a specialty drug requiring PA. If non-formulary, request a formulary exception with medical necessity documentation.

Can I get expedited review if my condition is urgent? Yes. Document immediate health risks from treatment delay. UnitedHealthcare must respond to urgent appeals within 72 hours.

Does step therapy apply to Dojolvi? No. UnitedHealthcare recognizes Dojolvi as the only FDA-approved therapy for LC-FAOD and doesn't require trying other treatments first.

What happens if I've already started Dojolvi? You can still appeal for coverage of ongoing treatment. Include documentation of clinical improvement and ongoing medical necessity.

Can my doctor file the appeal for me? Yes. Providers can submit appeals on behalf of patients and often have more success due to clinical expertise and direct payer relationships.

Sources & Further Reading

This guide is for informational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific guidance. For additional help with New Jersey insurance appeals, contact the NJ Department of Banking and Insurance at 1-800-446-7467.

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