By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Cigna in Ohio: Complete Coding, Appeals & Timeline Guide

Answer Box: Getting Dojolvi (Triheptanoin) Covered by Cigna in Ohio

Eligibility: Cigna covers Dojolvi for molecularly confirmed long-chain fatty acid oxidation disorders (LC-FAOD) with prior authorization. Fastest path: Submit PA through Express Scripts with genetic testing, specialist diet plan, and MCT oil discontinuation documentation. First step today: Contact your metabolic specialist to gather molecular confirmation and complete Cigna's PA form via ExpressPAth or CoverMyMeds portal. Standard review takes 3-15 business days; if denied, you have 180 days for internal appeal and 120 days for Ohio external review.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit Paths
  2. ICD-10 Mapping for LC-FAOD
  3. Product Coding: HCPCS, J-Codes, and NDC
  4. Clean Request Anatomy
  5. Frequent Coding Pitfalls
  6. Verification with Cigna Resources
  7. Quick Audit Checklist
  8. Appeals Playbook for Ohio
  9. Common Denial Reasons & Fixes
  10. FAQ

Coding Basics: Medical vs. Pharmacy Benefit Paths

Dojolvi (triheptanoin) typically processes through the pharmacy benefit via Cigna's Express Scripts, but understanding both pathways helps ensure clean submissions and faster approvals.

Pharmacy Benefit Path (Most Common)

  • Primary route: Express Scripts specialty pharmacy (usually Accredo)
  • NDC required: 69794-035-01 (500 mL bottle) or 69794-035-02 (4x500 mL pack)
  • Billing unit: Milliliters (mL) — each mL equals one billing unit
  • Prior authorization: Required through ExpressPAth or CoverMyMeds

Medical Benefit Path (Less Common)

  • When used: Buy-and-bill scenarios or specific plan structures
  • HCPCS code: J8499 (Prescription drug, oral, nonchemotherapeutic, NOS) or J3490 (Unclassified drugs)
  • NDC still required: Must accompany the HCPCS code
  • Administration codes: Not typically needed for oral liquid
Note: Always verify benefit coverage with Cigna before dispensing, as some plans may route specialty oral medications through medical benefits.

ICD-10 Mapping for LC-FAOD

Accurate diagnosis coding is critical for Dojolvi approval. Cigna requires molecular confirmation of long-chain fatty acid oxidation disorders.

Primary ICD-10 Codes

ICD-10 Code Description Documentation Requirements
E71.310 Long chain/very long chain acyl CoA dehydrogenase deficiency LCAD or VLCAD genetic confirmation
E71.318 Other disorders of fatty-acid oxidation LCHAD, TFP, or other LC-FAOD with molecular proof

Supporting Documentation Words

When documenting for these codes, include specific language that supports medical necessity:

  • "Molecularly confirmed" or "genetically confirmed"
  • "Pathogenic mutations in [specific gene]"
  • "CLIA-certified laboratory results"
  • "Characteristic acylcarnitine profile"
  • "Long-chain fatty acid oxidation disorder"

Counterforce Health helps clinicians identify the exact documentation language that resonates with Cigna's review criteria, turning complex genetic and metabolic evidence into targeted appeals that speak directly to payer policies.

Product Coding: HCPCS, J-Codes, and NDC

NDC Numbers and Package Sizes

  • 69794-035-01: 500 mL bottle (most common)
  • 69794-035-02: 4-pack of 500 mL bottles
  • 11-digit format: 69794003501 or 69794003502 for claims processing

HCPCS/J-Code Assignment

Cigna typically uses J8499 for Dojolvi when billing through medical benefits. Some regional variations may use J3490. Always confirm current codes with your Cigna representative.

Units Calculation and Conversion

Concentration: 1000 mg/mL (8.3 kcal/mL) Dosing calculation:

  1. Determine daily caloric intake (DCI) target
  2. Calculate Dojolvi calories needed: DCI × target percentage (up to 35%)
  3. Convert to volume: Dojolvi calories ÷ 8.3 kcal/mL = daily mL needed
  4. Billing units: Each mL = 1 billing unit (no conversion needed)

Example: 2000 kcal DCI at 30% = 600 kcal ÷ 8.3 = 72 mL daily = 72 billing units

Clean Request Anatomy

Essential PA Components for Cigna

Patient Information Block:

  • Cigna member ID and group number
  • Date of birth and demographics
  • ICD-10 code (E71.310 or E71.318)

Clinical Documentation:

  • Genetic testing report with specific mutations
  • Metabolic specialist prescription and oversight letter
  • Attestation of MCT oil discontinuation
  • Individualized diet plan from registered dietitian

Product Details:

  • NDC: 69794-035-01
  • Strength: 1000 mg/mL (8.3 kcal/mL)
  • Calculated daily dose in mL
  • Frequency: Minimum 4 divided doses daily

Justification Section:

  • Prior therapy failures (MCT oil intolerance/ineffectiveness)
  • Medical necessity rationale
  • Treatment goals and monitoring plan

Frequent Coding Pitfalls

Unit Conversion Errors

  • Wrong: Converting grams to different billing units
  • Right: Bill exact mL dispensed (1 mL = 1 billing unit)

Mismatched Benefit Coverage

  • Wrong: Submitting J-code when plan requires pharmacy benefit
  • Right: Verify benefit structure before coding

Missing Documentation

  • Wrong: Submitting without molecular confirmation
  • Right: Include genetic testing results with specific mutations

Concurrent MCT Products

  • Wrong: Not documenting MCT oil discontinuation
  • Right: Explicit attestation that all MCT products are stopped

Verification with Cigna Resources

Before Submission Checklist

  1. Confirm current NDC via Cigna formulary lookup
  2. Verify PA requirements through Express Scripts provider portal
  3. Check benefit coverage (pharmacy vs. medical)
  4. Validate ICD-10 codes against patient's genetic testing

Cigna Contact Points

  • Provider services: Number on back of patient's insurance card
  • ExpressPAth portal: For electronic PA submission
  • Accredo specialty pharmacy: For post-approval coordination

Quick Audit Checklist

Pre-Submission Review:

  • Correct NDC (69794-035-01 or -02)
  • Accurate ICD-10 (E71.310/E71.318)
  • Molecular confirmation attached
  • MCT discontinuation documented
  • Specialist diet plan included
  • Daily dose calculated correctly (mL)
  • Metabolic specialist involved
  • All required forms completed

Appeals Playbook for Ohio

Internal Appeals with Cigna

Timeline: Submit within 180 days of denial notice Process:

  1. Complete "Request for Health Care Professional Payment Review" form
  2. Submit to: Cigna Appeals Unit, PO Box 188011, Chattanooga, TN 37422
  3. Include all supporting documentation
  4. Expect decision within 60 days

Ohio External Review

Eligibility: After exhausting internal Cigna appeals Timeline: Request within 120 days of final Cigna denial Process:

  1. Complete Ohio External Review Request Form
  2. Submit to Ohio Department of Insurance
  3. Standard review: 30 days
  4. Expedited review: 72 hours (for urgent cases)

Contact: Ohio Department of Insurance Consumer Services: 1-800-686-1526

Tip: For rare disease denials, emphasize FDA orphan drug designation and specialty society guidelines in your external review request.

Common Denial Reasons & Fixes

Denial Reason Fix Strategy Documentation Needed
Missing molecular confirmation Submit genetic testing CLIA-certified lab report with mutations
Concurrent MCT use Document discontinuation Provider attestation, pharmacy records
Lack of specialist oversight Engage metabolic specialist Specialist prescription and monitoring plan
Quantity limits exceeded Justify dosing calculation Daily caloric needs assessment
Step therapy not met Document MCT failures Prior therapy records, adverse events

Healthcare systems often struggle with these complex appeals processes. Counterforce Health specializes in transforming insurance denials into evidence-backed appeals, particularly for specialty medications like Dojolvi where genetic confirmation and metabolic expertise are crucial for approval.

FAQ

How long does Cigna PA take for Dojolvi in Ohio? Standard review takes 3-15 business days through Express Scripts. Expedited reviews (for urgent medical situations) can be completed in 72 hours.

What if Dojolvi is non-formulary on my Cigna plan? Submit a formulary exception request with medical necessity documentation. Include genetic testing, specialist support, and evidence of MCT oil failure or intolerance.

Can I request an expedited appeal in Ohio? Yes, if delay would seriously jeopardize your health. Both Cigna internal appeals and Ohio external reviews offer expedited pathways with shortened timelines.

Does step therapy apply if I've never tried MCT oil? Cigna may require documented MCT oil trial unless contraindicated. Work with your specialist to document medical reasons why MCT oil cannot be used safely.

What billing code should I use for Dojolvi? Use NDC 69794-035-01 for pharmacy benefit claims. If billing through medical benefits, use J8499 with the NDC. Always verify current codes with Cigna.

How do I calculate the correct daily dose for billing? Use the formula: (Daily caloric intake × Dojolvi percentage) ÷ 8.3 kcal/mL = daily mL needed. Each mL equals one billing unit.

From Our Advocates

"We've seen Dojolvi approvals significantly improve when genetic testing results clearly specify the exact mutations and the metabolic specialist provides a comprehensive diet plan showing why MCT oil alternatives are insufficient. The key is connecting the molecular diagnosis directly to the clinical rationale for this specific therapy."

Sources & Further Reading

Disclaimer: This information is for educational purposes and should not replace professional medical or legal advice. Coverage policies vary by plan and change over time. Always verify current requirements with Cigna and consult healthcare professionals for medical decisions. For additional support with complex appeals, contact the Ohio Department of Insurance Consumer Services at 1-800-686-1526.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.