By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by Humana in Georgia: Complete Coding and Appeal Guide

Answer Box: Getting Dojolvi (Triheptanoin) Covered by Humana in Georgia

Dojolvi (triheptanoin) requires prior authorization from Humana Medicare Advantage, billed under NDC 69794-0050-50 with ICD-10 codes E71.310 or E71.318. Your prescriber must submit molecular genetic confirmation of long-chain fatty acid oxidation disorder (LC-FAOD) plus clinical documentation. If denied, you have 65 days to appeal and can request Georgia external review within 4 months. Start by having your doctor submit the PA request through Humana's provider portal with complete diagnostic records and treatment plan.

Table of Contents

  1. Coding Basics: Medical vs. Pharmacy Benefit
  2. ICD-10 Mapping for LC-FAOD
  3. Product Coding: NDC, Units, and Billing
  4. Clean Prior Authorization Request
  5. Frequent Coding Pitfalls
  6. Verification with Humana Resources
  7. Appeals Process in Georgia
  8. Quick Audit Checklist

Coding Basics: Medical vs. Pharmacy Benefit

Dojolvi (triheptanoin) is processed under the pharmacy benefit, not medical benefit, for virtually all Humana plans. This oral liquid medication requires specific NDC coding rather than J-codes used for injectable therapies.

Key Distinction:

  • Pharmacy Benefit: Uses NDC numbers, processed through pharmacy claims
  • Medical Benefit: Uses HCPCS/J-codes, processed through medical claims

For Dojolvi, you'll always use the pharmacy pathway with prior authorization required through Humana's Clinical Pharmacy Review.

ICD-10 Mapping for LC-FAOD

The primary ICD-10-CM codes for long-chain fatty acid oxidation disorders are:

ICD-10 Code Description When to Use
E71.310 Long chain/very long chain acyl CoA dehydrogenase deficiency VLCAD deficiency confirmed
E71.318 Other disorders of fatty-acid oxidation LCHAD, MTP deficiency, other LC-FAODs

Documentation Requirements:

  • Molecular genetic testing results showing pathogenic variants
  • Clinical phenotype consistent with LC-FAOD
  • Laboratory evidence (elevated acylcarnitines from newborn screening or confirmatory testing)
  • Specialist evaluation and treatment plan
Tip: Match the specific enzyme deficiency to the precise ICD-10 code. VLCAD uses E71.310, while LCHAD and other LC-FAODs use E71.318.

Product Coding: NDC, Units, and Billing

NDC Information

  • Product NDC: 69794-050
  • Package NDC: 69794-050-50
  • 11-digit format for billing: 69794-0050-50
  • Package size: 500 mL per bottle
  • Strength: 1,000 mg/mL (1 g/mL)

Billing Units

Dojolvi is billed per milliliter (mL). Each prescription should specify the exact mL quantity dispensed, matching the prescribed amount.

Unit Calculation Example:

  • Patient prescribed 50 mL daily
  • 30-day supply = 1,500 mL
  • Requires 3 bottles (500 mL each)
  • Bill as 1,500 units (mL)

Clean Prior Authorization Request

A successful PA request to Humana includes these essential components:

Required Documentation Checklist

  • Completed prior authorization form
  • ICD-10 diagnosis codes (E71.310 or E71.318)
  • Molecular genetic test results
  • Clinical history and exam findings
  • Previous dietary therapy attempts and outcomes
  • Specialist letter explaining medical necessity
  • Dosing calculation based on patient weight
  • Treatment goals and monitoring plan

Medical Necessity Letter Components

Your prescriber's letter should address:

  1. Confirmed LC-FAOD diagnosis with genetic testing results
  2. Prior treatment failures with standard dietary management
  3. Clinical rationale for Dojolvi specifically
  4. Dosing justification based on patient's caloric needs
  5. Expected outcomes and monitoring plan

Counterforce Health specializes in turning insurance denials into targeted, evidence-backed appeals by analyzing denial letters, plan policies, and clinical notes to craft point-by-point rebuttals aligned with each payer's specific requirements.

Frequent Coding Pitfalls

Common Errors to Avoid

Unit Conversion Mistakes

  • Billing in grams instead of mL
  • Incorrect quantity calculations for multi-bottle prescriptions
  • Missing decimal points in dosing

Code Mismatches

  • Using wrong ICD-10 code for specific LC-FAOD type
  • Submitting outdated NDC formats
  • Missing required 11-digit NDC format

Documentation Gaps

  • Incomplete genetic testing results
  • Missing specialist evaluation
  • Lack of prior therapy documentation
  • Insufficient dosing justification
Note: Humana requires molecular confirmation for LC-FAOD diagnosis. Newborn screening results alone may not be sufficient without confirmatory genetic testing.

Verification with Humana Resources

Before submitting your request:

  1. Check formulary status on Humana's drug lookup tool
  2. Verify PA requirements through the provider portal
  3. Confirm current NDC is active and correct format
  4. Review medical policy for Dojolvi coverage criteria
  5. Double-check billing units match prescribed quantity

Provider Resources

Appeals Process in Georgia

If Humana denies your Dojolvi request, Georgia offers multiple appeal levels:

Internal Appeals (Humana)

  • Timeline: 65 days from denial notice
  • Process: Submit through Humana member portal or mail
  • Required: Additional clinical documentation, prescriber letter
  • Expedited option: Available for urgent situations

External Review (Georgia DOI)

  • Eligibility: After internal appeal denial or urgent situations
  • Timeline: 4 months from final denial to request external review
  • Process: Submit written request to Georgia Department of Insurance
  • Cost: Free to consumer
  • Decision: Binding on Humana

Key Georgia-Specific Information

Georgia's external review process provides an independent third-party evaluation of medical necessity denials. The Georgia Office of Commissioner of Insurance and Fire Safety oversees this process and can be reached at 1-800-656-2298 for consumer assistance.

From our advocates: We've seen success when families combine detailed genetic testing results with specialist letters that specifically address Humana's coverage criteria. One case involved a VLCAD patient whose initial denial was overturned after the metabolic specialist provided additional documentation showing failed dietary management and specific caloric requirements that only Dojolvi could meet.

Quick Audit Checklist

Before submission, verify:

Coding Accuracy

  • Correct 11-digit NDC (69794-0050-50)
  • Appropriate ICD-10 code (E71.310 or E71.318)
  • Accurate unit calculation in mL
  • Proper quantity for days supply

Documentation Completeness

  • Molecular genetic test results attached
  • Specialist evaluation included
  • Prior therapy attempts documented
  • Medical necessity clearly explained
  • Dosing rationale provided

Submission Requirements

  • PA form completely filled out
  • All supporting documents attached
  • Prescriber signature and date
  • Patient demographics match insurance card
  • Submission method confirmed (portal vs. fax)

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required for coverage Humana PA portal
Molecular Confirmation Genetic testing proving LC-FAOD Lab reports, genetic counselor notes
Specialist Evaluation Metabolic specialist assessment Endocrinology or genetics clinic
ICD-10 Diagnosis E71.310 or E71.318 Medical records, billing system
NDC Format 69794-0050-50 (11-digit) FDA NDC database

When to Escalate

Contact these resources if you need additional help:

  • Humana Member Services: For PA status and appeals guidance
  • Georgia DOI Consumer Services: 1-800-656-2298 for external review help
  • Georgians for a Healthy Future: Consumer assistance organization
  • Counterforce Health: Specialized platform that helps turn insurance denials into successful appeals by analyzing payer policies and crafting evidence-backed rebuttals

FAQ

How long does Humana prior authorization take for Dojolvi in Georgia? Standard PA decisions take several business days, with expedited reviews available for urgent situations. By 2026, Humana commits to processing 95% of electronic PA requests within one business day.

What if Dojolvi is non-formulary on my Humana plan? You can request a formulary exception with medical necessity documentation. Your prescriber must explain why formulary alternatives are ineffective or cause adverse effects.

Can I request an expedited appeal in Georgia? Yes, both Humana internal appeals and Georgia external reviews offer expedited options when delays would seriously jeopardize health or function.

Does step therapy apply to Dojolvi? Step therapy requirements vary by plan, but given Dojolvi's unique mechanism for LC-FAOD, most plans don't require specific step therapy if diagnosis is confirmed.

What happens if I start Dojolvi before PA approval? You may be financially responsible for the full cost (approximately $5,857-$6,365 per 500-mL bottle) until coverage is approved.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Coverage policies and requirements may change. Verify current information with official sources before taking action.

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