How to Get Dojolvi (Triheptanoin) Covered by Cigna in Michigan: Appeals Guide and PA Requirements
Answer Box: Getting Dojolvi Covered by Cigna in Michigan
Fastest path to approval: Submit prior authorization with molecular confirmation of LC-FAOD, documentation of failed alternative therapies, and specialist letter of medical necessity. If denied, file internal appeal within 180 days, then Michigan DIFS external review within 127 days. Start today: Contact your prescribing physician to gather genetic testing results and treatment history records.
Table of Contents
- Why Michigan State Rules Matter
- Prior Authorization Standards and Turnarounds
- Step Therapy Protections in Michigan
- Continuity of Care During Insurance Transitions
- External Review and Complaints Process
- Practical Scripts and Sample Language
- Coverage Requirements at a Glance
- Common Denial Reasons and How to Fix Them
- Appeals Playbook for Cigna Michigan
- When to Escalate to State Regulators
Why Michigan State Rules Matter
Michigan's insurance regulations work alongside Cigna's national policies to create specific protections for patients needing specialty medications like Dojolvi (triheptanoin). The state's Patient's Right to Independent Review Act gives you 127 days—longer than the federal standard—to file for external review after Cigna's final denial.
Michigan patients benefit from relatively strong continuity-of-care protections during plan transitions, with up to 180 days of coverage for ongoing specialty medications in certain programs. However, these protections vary by coverage type: employer plans governed by ERISA have different rules than individual or Medicaid plans.
Key difference: Michigan's external review timeline of 127 days (about 4 months) gives you more time than many states to gather comprehensive medical documentation for your appeal.
Prior Authorization Standards and Turnarounds
Cigna processes Dojolvi prior authorizations through Express Scripts/Accredo for specialty medications. Here's what to expect:
Standard Timeline:
- 72 hours for routine PA decisions
- 24 hours for urgent/expedited requests
- 180 days to file internal appeals after denial
Renewal Requirements: Most specialty medications require annual reauthorization with updated clinical documentation showing continued medical necessity and treatment response.
Tip: Request expedited review if delaying Dojolvi would seriously jeopardize your health—this requires your physician to document the urgency in writing.
Step Therapy Protections in Michigan
Under Michigan law, you can request a medical exception to Cigna's step therapy requirements if preferred alternatives have failed or are medically inappropriate. Your doctor must document:
- Clinical failure of formulary alternatives (MCT oil, dietary modifications)
- Intolerance or contraindications to preferred treatments
- Medical necessity for Dojolvi specifically for your LC-FAOD diagnosis
Required Documentation:
- Prior treatment records showing doses, duration, and outcomes
- Molecular confirmation of long-chain fatty acid oxidation disorder
- Specialist letter explaining why alternatives are insufficient
The Michigan DIFS external review process will evaluate whether Cigna properly applied their step therapy criteria to your specific medical situation.
Continuity of Care During Insurance Transitions
If you're switching to or from Cigna while taking Dojolvi, Michigan provides specific protections:
Medicaid Transitions:
- 180 days of continued coverage for specialty services if you're in PIHP programs
- 90 days for standard Medicaid enrollees
- Plans must honor existing specialist relationships and medication regimens
Commercial Insurance: Federal COBRA requirements apply, but Michigan doesn't mandate specific continuity periods for employer plans beyond federal minimums.
Note: Contact both your old and new plan immediately when transitioning to ensure uninterrupted Dojolvi access.
External Review and Complaints Process
After Cigna issues a final denial, you have powerful appeal rights in Michigan:
Michigan DIFS External Review:
- File within 127 days of final internal denial
- 60 days for standard review decisions
- 72 hours for expedited reviews (with physician letter documenting urgency)
- Submit online at DIFS External Review portal or call 877-999-6442
What to Include:
- Complete medical records supporting LC-FAOD diagnosis
- Genetic testing confirming molecular basis
- Documentation of failed alternative treatments
- Specialist letters of medical necessity
- All Cigna denial letters and internal appeal responses
Independent Review Organizations (IROs) assigned by DIFS have medical expertise in rare diseases and will evaluate whether Cigna's denial was appropriate under your policy terms and medical evidence.
Practical Scripts and Sample Language
When calling Cigna member services: "I need to request prior authorization for Dojolvi for molecularly confirmed LC-FAOD. This is a rare disease with FDA-approved treatment. Can you connect me with the specialty pharmacy team or provide the PA submission process?"
For internal appeals: "Under Michigan's Patient's Right to Independent Review Act, I'm appealing this denial. The attached molecular confirmation and specialist documentation demonstrate medical necessity for Dojolvi as the only FDA-approved treatment for long-chain fatty acid oxidation disorders."
Requesting expedited review: "My physician has documented that delaying this treatment would seriously jeopardize my health due to the progressive nature of LC-FAOD. I request expedited processing under Michigan regulations."
Coverage Requirements at a Glance
| Requirement | What It Means | Where to Find It | Source |
|---|---|---|---|
| Prior Authorization | Required before dispensing | Cigna formulary or provider portal | Cigna PA Guidelines |
| Molecular Confirmation | Genetic testing proving LC-FAOD | Lab results, genetic counselor report | Cigna Genetic Testing Policy |
| Specialty Pharmacy | Must use Accredo/Express Scripts network | Insurance card or member portal | Express Scripts Specialty |
| Internal Appeal Deadline | 180 days from denial date | Denial letter footer | Cigna Appeals Process |
| External Review Deadline | 127 days from final denial | Michigan DIFS website | Michigan Appeals Law |
Common Denial Reasons and How to Fix Them
| Denial Reason | How to Overturn | Required Documents |
|---|---|---|
| "Not medically necessary" | Submit specialist letter with FDA labeling citations | LC-FAOD diagnosis, treatment history, FDA approval documentation |
| "Missing molecular confirmation" | Provide genetic testing results | Laboratory report confirming pathogenic variants |
| "Concurrent MCT use" | Document discontinuation of other medium-chain triglycerides | Updated medication list, physician attestation |
| "Quantity limits exceeded" | Justify dosing based on caloric needs and weight | Dietitian assessment, dosing calculations, growth charts |
| "Non-formulary drug" | Request formulary exception with medical necessity | Prior failed treatments, contraindications to alternatives |
Appeals Playbook for Cigna Michigan
Level 1: Internal Appeal
- Timeline: File within 180 days of denial
- Review period: 60 days for standard, 24 hours for expedited
- How to file: Written request via Cigna appeals portal or fax
- Required: Medical records, denial letter, physician support
Level 2: External Review (Michigan DIFS)
- Timeline: File within 127 days of final internal denial
- Review period: 60 days standard, 72 hours expedited
- How to file: Online form or call 877-999-6442
- Cost: Free to patients
- Decision: Binding on Cigna if favorable
From our advocates: We've seen Michigan external reviews succeed when families provide comprehensive genetic testing documentation alongside detailed treatment failure records. The IRO medical experts understand rare diseases better than initial PA reviewers, making thorough documentation crucial for overturning denials.
When to Escalate to State Regulators
Contact Michigan DIFS if Cigna:
- Fails to meet PA decision deadlines (72 hours standard, 24 hours urgent)
- Denies expedited appeals without proper medical review
- Doesn't honor external review decisions
- Violates continuity of care requirements during transitions
Michigan DIFS Contact:
- Phone: 877-999-6442
- Website: michigan.gov/difs
- Complaint portal available online for formal regulatory action
Limits and Caveats
ERISA Plans: Self-funded employer plans have federal oversight and may not follow all Michigan state protections. Check your plan documents or ask HR about your specific appeal rights.
Medicaid vs. Commercial: Different appeal pathways apply. Medicaid appeals go through administrative hearings, while commercial plans use the DIFS external review process.
Network Requirements: Cigna may require you to use specific specialty pharmacies (Accredo) or providers for Dojolvi administration and monitoring.
About Counterforce Health
Counterforce Health helps patients, clinicians, and specialty pharmacies navigate insurance denials by creating targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to draft point-by-point rebuttals that align with each payer's specific requirements, pulling the right clinical evidence and regulatory citations to support medical necessity arguments.
For complex cases like Dojolvi coverage, having professional appeal support can significantly improve approval odds by ensuring all molecular confirmation requirements, step therapy exceptions, and Michigan-specific procedural requirements are properly addressed in your submission.
Frequently Asked Questions
How long does Cigna prior authorization take for Dojolvi in Michigan? Standard PA decisions take 72 hours; expedited requests are completed within 24 hours if your physician documents medical urgency.
What if Dojolvi is non-formulary on my Cigna plan? You can request a formulary exception by documenting medical necessity and failed alternatives. The process follows the same PA pathway with additional clinical justification requirements.
Can I request an expedited appeal in Michigan? Yes, both Cigna internal appeals and Michigan DIFS external reviews offer expedited pathways (24 hours and 72 hours respectively) when your physician confirms that delays would seriously jeopardize your health.
Does step therapy apply if I've tried treatments outside Michigan? Yes, Cigna accepts documentation of prior treatment failures regardless of where they occurred, as long as you provide complete medical records and physician attestation.
What counts as molecular confirmation for LC-FAOD? Genetic testing showing pathogenic or likely pathogenic variants in genes associated with long-chain fatty acid oxidation disorders, performed at a certified laboratory with results that directly support the diagnosis.
How much does Dojolvi cost without insurance? Cash prices typically range from $5,857 to $6,365 per 500-mL bottle, making insurance coverage essential for most patients.
Sources and Further Reading
- Cigna Prior Authorization Guidelines
- Michigan DIFS External Review Process
- Cigna Genetic Testing Coverage Policy
- Express Scripts Specialty Pharmacy Appeals
- FDA Dojolvi Prescribing Information
- Michigan Patient's Right to Independent Review Act
Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance coverage decisions depend on your specific plan terms and medical circumstances. Always consult with your healthcare provider and insurance plan directly for guidance on your individual situation. For assistance with Michigan insurance complaints or appeals, contact DIFS at 877-999-6442.
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