By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (triheptanoin) Covered by Humana in North Carolina: Complete PA Guide and Appeal Process

Answer Box: Getting Dojolvi Covered by Humana in North Carolina

Eligibility: You need molecular genetic confirmation of long-chain fatty acid oxidation disorder (LC-FAOD) and must discontinue all MCT products before starting Dojolvi. Fastest path: Submit prior authorization via Humana's provider portal with genetic testing results, specialist letter, and dosing calculations based on weight/caloric needs. First step today: Contact your metabolic specialist to order molecular confirmation testing (free through Invitae's LC-FAOD program) and request a medical necessity letter. Humana typically decides within 72 hours for standard requests, 24 hours for expedited cases.

Table of Contents

  1. How to Use This Guide
  2. Eligibility Triage: Do You Qualify?
  3. If You're Likely Eligible: Document Checklist
  4. If You're Possibly Eligible: Tests to Request
  5. If Not Yet Eligible: Alternative Paths
  6. If Denied: North Carolina Appeal Options
  7. Coverage Requirements at a Glance
  8. Common Denial Reasons & How to Fix Them
  9. FAQ: Humana and Dojolvi in North Carolina
  10. Sources & Further Reading

How to Use This Guide

This guide walks you through getting Dojolvi (triheptanoin) covered by Humana in North Carolina, from initial eligibility through appeals. Dojolvi is the only FDA-approved treatment for long-chain fatty acid oxidation disorders (LC-FAOD), but it requires strict prior authorization with molecular genetic proof.

Start here: Work through the eligibility triage below to determine your path. If you're already diagnosed with LC-FAOD, jump to the document checklist. If you've been denied, skip to the appeals section.

For urgent situations: Call Humana at 800-555-2546 to request expedited review if delays could harm your health.

Eligibility Triage: Do You Qualify?

Likely Eligible ✅

  • Molecular genetic confirmation of LC-FAOD (VLCAD, LCHAD, CPT I/II deficiency, or other LC-FAOD)
  • Currently using MCT oil or other dietary therapy with poor outcomes
  • Under care of metabolic/genetics specialist
  • No pancreatic insufficiency

Possibly Eligible ⚠️

  • Positive newborn screening for LC-FAOD but no genetic confirmation yet
  • Clinical suspicion based on symptoms (recurrent rhabdomyolysis, cardiomyopathy, liver dysfunction)
  • Family history of LC-FAOD with concerning symptoms

Not Yet Eligible ❌

  • No LC-FAOD diagnosis or genetic testing
  • Using Dojolvi for non-LC-FAOD conditions
  • Concurrent pancreatic insufficiency
  • Still using MCT products (must discontinue first)

If You're Likely Eligible: Document Checklist

Required Documentation for Humana PA

1. Genetic Testing Results

2. Specialist Medical Necessity Letter Must include:

  • Confirmed LC-FAOD diagnosis with ICD-10 codes (E71.310 for VLCADD or E71.318 for other LC-FAOD)
  • Clinical history and exam findings
  • Prior dietary therapy outcomes (MCT oil failures/intolerance)
  • Rationale for Dojolvi over alternatives
  • Dosing calculation based on patient weight and caloric needs
  • Treatment goals and monitoring plan

3. Clinical Documentation

  • Chart notes documenting LC-FAOD symptoms and management
  • Laboratory results (acylcarnitine profiles, CK levels during episodes)
  • Documentation of MCT product discontinuation

Submission Process

  1. Complete Humana PA form with patient demographics and prescriber signature
  2. Submit electronically via Humana provider portal (preferred) or fax to 877-486-2621
  3. Include NDC: 69794-0050-50 for Dojolvi 500mL bottles
  4. Verify formulary status on Humana's 2026 drug list (requires PA)
Tip: Submit during business hours for faster processing. Humana's clinical pharmacy team reviews specialty drug requests within 72 hours for standard cases.

If You're Possibly Eligible: Tests to Request

Molecular Genetic Testing

Free option: Invitae LC-FAOD sponsored testing program

  • Covers up to 21 genes including ACADM, ACADVL, CPT1A, CPT2, HADHA, HADHB
  • Eligible if acylcarnitine test performed or UltraCare Start Form completed
  • Results in 10-21 days
  • No insurance prior authorization required

What to track while waiting:

  • Document any metabolic episodes (symptoms, triggers, CK levels)
  • Keep records of current dietary therapy and outcomes
  • Schedule follow-up with metabolic specialist

Timeline to reapply: Once genetic results confirm LC-FAOD diagnosis, you can immediately submit PA with complete documentation.

If Not Yet Eligible: Alternative Paths

Dietary Management Options

While pursuing Dojolvi approval:

  • Continue MCT oil under specialist guidance (must discontinue before starting Dojolvi)
  • Maintain emergency protocols for metabolic crises
  • Consider clinical trial participation through ClinicalTrials.gov

Preparing for Exception Requests

If standard criteria aren't met:

  • Document why alternatives are inadequate
  • Gather supporting literature on Dojolvi's unique mechanism
  • Request peer-to-peer review with Humana's medical director

Note: Dojolvi is the only FDA-approved therapy specifically for LC-FAOD, which strengthens medical necessity arguments.

If Denied: North Carolina Appeal Options

North Carolina offers robust appeal rights through internal Humana processes and state-level external review.

Level 1: Internal Humana Appeal

  • Deadline: 65 days from denial notice
  • Timeline: 72 hours for standard, 24 hours for expedited
  • How to file: Call 800-555-2546, submit via provider portal, or fax 877-486-2621
  • Include: Additional clinical documentation, specialist letter addressing denial reasons

Level 2: Smart NC External Review

If Humana's internal appeal fails, North Carolina residents can request independent external review.

Eligibility:

  • State-regulated Humana plan (not self-funded employer plans)
  • Exhausted internal appeals or qualify for expedited review
  • Denial based on medical necessity, experimental treatment, or similar coverage issues

How to file:

  • Deadline: 120 days from final internal denial
  • Contact: Smart NC at 1-855-408-1212 (free advocacy)
  • Timeline: 45 days for standard review, 72 hours for expedited

Success factors:

  • Detailed documentation of prior therapy failures
  • Strong provider support with medical necessity letter
  • Evidence comparing Dojolvi to alternatives for LC-FAOD
From our advocates: "We've seen several LC-FAOD cases succeed at external review when the initial denial cited 'experimental' status. The key was emphasizing FDA approval specifically for LC-FAOD and Dojolvi's unique mechanism compared to standard MCT therapy. Having the metabolic specialist available for peer-to-peer review also helped."

Coverage Requirements at a Glance

Requirement Details Source
Diagnosis Codes E71.310 (VLCADD) or E71.318 (other LC-FAOD) Humana Policy
NDC Code 69794-0050-50 (500mL bottle) FDA Label
Prior Authorization Required for all Humana plans 2026 PA List
Molecular Testing Pathogenic variants in LC-FAOD genes required Humana Policy
MCT Discontinuation Must stop all MCT products before starting FDA Label
Specialist Requirement Metabolic/genetics specialist involvement Humana Policy

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing genetic confirmation Submit molecular testing results showing pathogenic LC-FAOD variants
Concurrent MCT use Document complete discontinuation of all MCT products
Lack of specialist involvement Obtain letter from metabolic/genetics specialist
Insufficient prior therapy documentation Provide detailed records of MCT oil trials and outcomes
Quantity limits exceeded Include dosing calculations based on weight and caloric needs (up to 35% DCI)
"Experimental" determination Emphasize FDA approval specifically for LC-FAOD; cite unique mechanism vs. MCT

FAQ: Humana and Dojolvi in North Carolina

Q: How long does Humana prior authorization take in North Carolina? A: Standard requests receive decisions within 72 hours. Expedited requests (for urgent medical situations) are decided within 24 hours.

Q: What if Dojolvi is non-formulary on my Humana plan? A: Request a formulary exception through Humana's provider portal or by calling 800-555-2546. Include a prescriber statement explaining why formulary alternatives are ineffective.

Q: Can I request expedited review if my child has frequent metabolic crises? A: Yes. If delays could seriously jeopardize health or function, request expedited review. Document the urgency in your submission.

Q: Does step therapy apply if I failed MCT therapy in another state? A: Provide documentation of prior therapy failures regardless of location. Humana accepts out-of-state medical records for step therapy requirements.

Q: What's the cost of Dojolvi without insurance? A: Cash prices range from $5,857-$6,365 per 500mL bottle. Check Ultragenyx's patient assistance programs for financial support options.

Q: How do I know if my Humana plan is state-regulated for Smart NC appeals? A: Check your plan documents or call Humana member services. Self-funded employer plans are typically excluded from state external review processes.

Counterforce Health helps patients and providers navigate complex prior authorization requirements for specialty medications like Dojolvi. Their platform analyzes denial letters and insurance policies to create targeted, evidence-based appeals that address specific coverage criteria. By automating much of the appeals process, Counterforce Health reduces the administrative burden on healthcare teams while improving approval rates for medically necessary treatments.

For patients facing Dojolvi denials, having expert support can make the difference between prolonged delays and timely access to this life-saving therapy. The platform's payer-specific workflows ensure appeals meet Humana's exact requirements while incorporating the clinical evidence and procedural details that coverage decisions demand.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Coverage decisions depend on individual plan terms and clinical circumstances. Always consult your healthcare provider about treatment options and contact your insurance company or North Carolina Department of Insurance for plan-specific guidance.

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