By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Cigna in New York: Complete PA Guide with Appeal Scripts

Answer Box: Getting Dojolvi Covered by Cigna in New York

Eligibility: Patients with molecularly confirmed long-chain fatty acid oxidation disorders (LC-FAOD) can get Dojolvi (triheptanoin) covered by Cigna through prior authorization.

Fastest path: Submit PA with genetic testing results, metabolic specialist prescription, and documentation that no other MCT products are being used concurrently. Cigna requires 12-month authorizations with clinical evidence.

First step today: Contact your metabolic specialist to gather molecular confirmation documentation and request a letter of medical necessity. Call Cigna at the number on your member ID card to confirm current PA forms and submission method.

Table of Contents

  1. Who Should Use This Guide
  2. Member & Plan Basics
  3. Clinical Criteria Requirements
  4. Coding & Documentation
  5. Documentation Packet Checklist
  6. Submission Process
  7. Specialty Pharmacy Routing
  8. After Submission: What to Expect
  9. Common Denial Reasons & How to Fix Them
  10. Appeals Process in New York
  11. Cost Savings Options
  12. Frequently Asked Questions

Who Should Use This Guide

This comprehensive checklist is designed for patients with long-chain fatty acid oxidation disorders (LC-FAOD) and their healthcare teams seeking Cigna coverage for Dojolvi (triheptanoin) in New York.

Use this guide if you:

  • Have a molecularly confirmed LC-FAOD diagnosis
  • Are prescribed Dojolvi by a metabolic specialist
  • Hold active Cigna insurance coverage in New York
  • Need to navigate prior authorization or appeal a denial

Expected outcome: Following this checklist significantly improves your chances of first-time approval. If denied initially, the appeal strategies outlined here leverage New York's strong consumer protection laws, where Cigna showed a 50.74% internal appeal reversal rate in 2024—well above the industry average.

Member & Plan Basics

Verify Your Coverage Status

Before starting the PA process, confirm these essential details:

  • Active Cigna coverage: Check your member portal or call the number on your ID card
  • Plan type: Commercial, Medicare Advantage, or Medicaid managed care
  • Deductible status: High-deductible plans may require meeting deductible first
  • Specialty pharmacy requirement: Most Cigna plans require specialty drugs through Express Scripts/Accredo
Note: Dojolvi typically costs $5,857–$6,365 per 500-mL bottle, making prior authorization essential for most patients.

Clinical Criteria Requirements

Cigna's 2024 prior authorization requirements for Dojolvi are highly specific:

Must-Have Requirements

Requirement Documentation Needed Source
Molecularly confirmed LC-FAOD Genetic testing lab reports Cigna Policy
No concurrent MCT use Provider attestation Cigna Policy
Metabolic specialist involvement Prescription by or consultation with specialist Cigna Policy
Clinical qualification One of: MCT intolerance, severe LC-FAOD manifestations, or current Dojolvi use Cigna Policy

Authorization Duration

  • Initial approval: 12 months
  • Reauthorization: Requires evidence of positive clinical response and continued compliance

Coding & Documentation

Required Medical Codes

ICD-10 Diagnosis Codes:

  • E71.310: Long chain/very long chain acyl CoA dehydrogenase deficiency
  • E71.318: Other disorders of fatty-acid oxidation

HCPCS J-Code:

  • J1212: Injection, triheptanoin, per 1 gram
Tip: Ensure your provider uses the specific ICD-10 code that matches your genetic testing results for the most accurate billing.

Documentation Packet Checklist

Essential Documents

Clinical Documentation:

  • Genetic testing results confirming specific LC-FAOD type
  • Current provider notes from metabolic specialist
  • Documentation of prior MCT trials/failures (if applicable)
  • Evidence of LC-FAOD complications (cardiomyopathy, rhabdomyolysis, hypoglycemia)

Insurance Forms:

  • Completed Cigna prior authorization form
  • Letter of medical necessity from metabolic specialist
  • Prescription with specific dosing instructions

Supporting Evidence:

  • FDA labeling information for Dojolvi
  • Relevant clinical guidelines or peer-reviewed studies
  • Prior therapy documentation showing inadequate response

Medical Necessity Letter Components

Your metabolic specialist's letter should include:

  1. Patient identification: Full name, DOB, Cigna ID, group number
  2. Confirmed LC-FAOD diagnosis with genetic testing details
  3. Clinical history: Disease manifestations, severity, complications
  4. Treatment rationale: Why Dojolvi is medically necessary
  5. Specialist credentials: Board certification in medical genetics/metabolism
  6. Supporting literature: FDA approval, clinical guidelines, relevant studies

Submission Process

Step-by-Step Submission

  1. Gather all documentation (use checklist above)
  2. Complete Cigna PA forms (verify current version with Cigna)
  3. Submit via preferred method:
    • Cigna provider portal (fastest)
    • Fax to Cigna PA department
    • Mail to address on PA form
  4. Keep detailed records of submission date, confirmation numbers
  5. Follow up within 5-7 business days to confirm receipt
Important: Cigna has 180 days for internal appeals, but initial PA decisions typically come within 15 business days for non-urgent requests.

Specialty Pharmacy Routing

Most Cigna plans require Dojolvi through Express Scripts/Accredo specialty pharmacy:

Transfer Process

  1. Provider submits PA and receives approval
  2. Prescription sent to Accredo specialty pharmacy
  3. Patient enrollment in specialty pharmacy program
  4. Shipment coordination for temperature-controlled delivery
  5. Ongoing refill management through Accredo

Contact Accredo directly for current transfer forms and requirements.

After Submission: What to Expect

Timeline & Status Tracking

  • Initial review: 3-5 business days for completeness
  • Clinical determination: 10-15 business days for standard requests
  • Approval notification: Via provider portal, phone, or mail
  • Denial notification: Includes specific reason codes and appeal rights

What to Record

  • Submission confirmation numbers
  • Case reference numbers
  • Representative names and call dates
  • All correspondence received

Common Denial Reasons & How to Fix Them

Denial Reason Solution Required Documentation
Missing molecular confirmation Submit complete genetic testing results Lab reports with specific LC-FAOD gene mutations
Concurrent MCT use Provider attestation of MCT discontinuation Updated medication list, provider letter
Non-specialist prescriber Involve metabolic specialist Consultation notes, specialist prescription
Insufficient clinical justification Strengthen medical necessity letter Clinical manifestations, treatment failures, guidelines

Appeals Process in New York

New York offers robust appeal rights for Cigna denials:

Internal Appeals (First Step)

  • Timeline: File within 180 days of denial
  • Process: Submit appeal letter with additional documentation
  • Decision: Within 60 days for standard appeals

External Appeals (New York DFS)

  • Timeline: File within 4 months of final internal denial
  • Process: New York Department of Financial Services independent review
  • Cost: Maximum $25 fee (waived for financial hardship/Medicaid)
  • Decision: Binding on Cigna if overturned
Expedited appeals: Available for urgent needs—decisions within 72 hours (24 hours for urgent drug denials).

For assistance, contact Community Health Advocates at 888-614-5400.

Cost Savings Options

Financial Assistance Programs

  • Ultragenyx Patient Support: UltraCare Support program for eligible patients
  • Manufacturer copay assistance: May reduce out-of-pocket costs
  • State programs: New York Medicaid expansion covers many low-income adults
  • Foundation grants: Check rare disease foundations for LC-FAOD support
Note: Copay assistance programs typically cannot be combined with government insurance (Medicare/Medicaid).

Frequently Asked Questions

How long does Cigna prior authorization take for Dojolvi in New York?

Standard PA requests typically take 10-15 business days. Urgent requests can be expedited to 72 hours with appropriate clinical justification.

What if Dojolvi is non-formulary on my Cigna plan?

You can request a formulary exception with your metabolic specialist's support, emphasizing that Dojolvi is the only FDA-approved therapy for LC-FAOD.

Can I request an expedited appeal in New York?

Yes, New York allows expedited external appeals for urgent medical needs, with decisions within 72 hours (24 hours for urgent drug denials).

Does step therapy apply if I've tried MCT supplements outside New York?

Prior MCT trials from any location should count toward meeting Cigna's step therapy requirements, provided you have proper documentation.

What happens if my internal appeal is denied?

You can file an external appeal with the New York Department of Financial Services within 4 months of the final internal denial.

How do I find a metabolic specialist in New York?

Contact major medical centers like NewYork-Presbyterian, NYU Langone, or Mount Sinai, which typically have medical genetics departments.

From Our Advocates

"We've seen patients succeed by building a comprehensive documentation packet before their first submission. One family gathered genetic testing results, prior MCT trial records, and hospital admission notes from metabolic crises—their PA was approved on the first try. The key is showing Cigna that you meet every single criterion in their policy, leaving no room for doubt."

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals. Our platform analyzes denial letters and plan policies to create point-by-point rebuttals aligned with each payer's specific requirements, significantly improving approval rates for complex specialty medications like Dojolvi.

When facing a Cigna denial for Dojolvi, having the right documentation and appeal strategy makes all the difference. Counterforce Health's specialized approach to payer-specific workflows can help ensure your appeal addresses Cigna's exact criteria while meeting New York's procedural requirements.

Sources & Further Reading

Disclaimer: This guide is for informational purposes only and does not constitute medical or legal advice. Coverage policies and appeal procedures may change. Always verify current requirements with Cigna and consult your healthcare team for medical decisions. For additional assistance with insurance appeals in New York, contact Community Health Advocates at 888-614-5400 or the New York Department of Financial Services consumer helpline.

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