By Counterforce Health Team in Dojolvi (triheptanoin) —

How to Get Dojolvi (Triheptanoin) Covered by UnitedHealthcare in Texas: Complete PA Guide with Appeal Scripts

Answer Box: Getting Dojolvi Covered by UnitedHealthcare in Texas

UnitedHealthcare requires prior authorization for Dojolvi (triheptanoin) with molecular confirmation of LC-FAOD via genetic testing or enzyme activity. In Texas, you have strong appeal rights including expedited external review through Independent Review Organizations. First step today: Contact your board-certified medical geneticist to initiate the PA request via UnitedHealthcare's provider portal, ensuring you have genetic test results and dietitian documentation ready.

Table of Contents

Coverage at a Glance

Requirement What It Means Where to Find It Source
Prior Authorization Required for all LC-FAOD cases UnitedHealthcare Provider Portal UHC PA Policy
Molecular Confirmation Genetic testing showing pathogenic mutations in CPT2, ACADVL, HADHA, or HADHB Lab reports from certified genetics lab UHC PA Policy
Prescriber Requirement Board-certified medical geneticist Provider credentials verification UHC PA Policy
Dosing Limit ≤35% of daily caloric intake Dietitian calculation UHC PA Policy
No Concurrent MCTs Must discontinue other medium-chain triglycerides Medication reconciliation UHC PA Policy
Appeals Deadline 180 days from denial Denial letter instructions Texas Insurance Code

Step-by-Step: Fastest Path to Approval

1. Confirm Your Diagnosis Documentation

Who: Patient and medical geneticist
What: Gather molecular confirmation via genetic testing showing pathogenic mutations in LC-FAOD genes (CPT2, ACADVL, HADHA, HADHB) OR elevated disease-specific acylcarnitines OR low enzyme activity in cultured fibroblasts.
Timeline: Can take 2-4 weeks for genetic testing if not already completed
Source: UHC PA Requirements

2. Ensure Proper Prescriber Credentials

Who: Patient verification
What: Confirm your doctor is a board-certified medical geneticist experienced in LC-FAOD treatment.
Timeline: Immediate verification
Texas Specialists: Texas Children's Hospital (Houston), UT Southwestern (Dallas), Dell Children's (Austin)

3. Complete Dietary Management Documentation

Who: Metabolic dietitian
What: Document ongoing disease-related dietary management and calculate proper dosing (≤35% daily caloric intake in ≥4 divided doses).
Timeline: 1-2 appointments
Formula: Total mL = DCI kcal × target % ÷ 8.3 kcal/mL

4. Submit Prior Authorization Request

Who: Medical geneticist or clinic staff
What: Submit via UnitedHealthcare Provider Portal with all required documentation.
Timeline: Up to 24 hours for standard review; automated approvals possible
Source: OptumRx PA Process

5. Monitor Status and Follow Up

Who: Patient or provider
What: Check status at optumrx.com or call 866-441-2422
Timeline: 24-48 hours for decision
Next Step: If denied, immediately request peer-to-peer review before formal appeal

Texas Prior Authorization Laws That Help

Texas provides strong patient protections that work in your favor when appealing Dojolvi denials.

Step Therapy Exception Rights

Under Texas Insurance Code Section 1369.0546, UnitedHealthcare must grant step therapy exceptions if your provider documents that:

  • The required alternative drug is contraindicated or will likely cause adverse reactions
  • You previously discontinued the same or similar drug due to ineffectiveness or adverse events
  • The required drug is not clinically appropriate due to treatment barriers or functional limitations
  • You're currently stable on Dojolvi and switching would cause harm

Key Timeline: UnitedHealthcare has only 72 hours to deny your exception request. If they don't respond within this timeframe, your request is automatically approved.

Continuity of Care Protections

If you're already on Dojolvi and experience plan changes or provider network exits, Texas law typically provides a 90-day transition period where you can continue receiving in-network benefits for ongoing specialty treatments like LC-FAOD therapy.

Medical Necessity Documentation

Clinician Corner: Medical Necessity Letter Checklist

Your medical geneticist's letter should include these specific elements for UnitedHealthcare approval:

Patient Information & Diagnosis

  • Confirmed LC-FAOD diagnosis with molecular/genetic confirmation
  • Specific gene mutations identified (e.g., ACADVL c.848T>C)
  • Clinical history supporting diagnosis (rhabdomyolysis episodes, hypoglycemia, cardiomyopathy)

Prior Treatments & Outcomes

  • Previous dietary management attempts and limitations
  • Any adverse reactions to MCT products (if applicable)
  • Hospitalizations or complications from LC-FAOD

Clinical Rationale for Dojolvi

  • Why Dojolvi is medically necessary as the only FDA-approved LC-FAOD therapy
  • Expected clinical benefits (reduced rhabdomyolysis, improved cardiac function)
  • Integration with ongoing metabolic dietary management

Dosing & Monitoring Plan

  • Calculated dose ≤35% of daily caloric intake
  • Administration schedule (≥4 divided doses daily)
  • Monitoring plan for liver function, carnitine levels, and symptoms

Guideline Citations

Appeals Playbook for UnitedHealthcare in Texas

Internal Appeal Process

Level 1: Standard Internal Appeal

  • Deadline: 180 days from denial date
  • Timeline: 30 days for pre-service requests, 60 days for post-service
  • How to File: Via UnitedHealthcare member portal, phone (number on denial letter), or mail
  • Required: Denial letter, medical records, prescriber letter of medical necessity

Expedited Internal Appeal

  • When: If delay would seriously jeopardize your health
  • Timeline: 72 hours for decision
  • How: Mark submission "EXPEDITED" with physician statement of urgency

Peer-to-Peer Review Option

Before formal appeals, request a peer-to-peer review where your medical geneticist speaks directly with UnitedHealthcare's medical director.

How to Request: Call OptumRx at 866-441-2422 and ask for peer-to-peer review Timeline: Must be scheduled within 3 business days for inpatient, 21 days for outpatient Advantage: Often resolves denials without formal appeal process

External Review Through Texas

If internal appeals fail, Texas law guarantees independent external review through an Independent Review Organization (IRO).

Eligibility: Medical necessity disputes after completing internal appeals Deadline: 4 months from final internal denial Timeline: 20 days for standard review, 72 hours for expedited Cost: Paid by UnitedHealthcare Binding: If IRO overturns denial, UnitedHealthcare must comply

How to File: Contact Texas Department of Insurance at 1-800-252-3439

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing molecular confirmation Submit genetic test results showing pathogenic mutations in LC-FAOD genes (UHC requirements)
Concurrent MCT use Provide medication reconciliation showing discontinuation of all MCT products
Lack of specialist prescriber Verify board-certified medical geneticist credentials and LC-FAOD experience
Quantity limits exceeded Submit dietitian calculation showing dose ≤35% daily caloric intake with proper formula
"Not medically necessary" Cite FDA approval for LC-FAOD, lack of alternatives, and clinical improvement goals
Missing dietary management Include metabolic dietitian notes documenting ongoing LC-FAOD dietary therapy

When to Escalate: Texas External Review

Escalate to Texas regulators when:

  • UnitedHealthcare violates appeal timelines (72 hours for step therapy exceptions, 30 days for standard appeals)
  • Denials appear to contradict their own published policies
  • You suspect bad faith claim handling

Texas Department of Insurance: 1-800-252-3439
Office of Public Insurance Counsel: 1-877-611-6742
IRO Information Line: 1-866-554-4926

Costs & Patient Assistance

Dojolvi's cash price ranges from $5,857-$6,365 per 500-mL bottle, making coverage crucial for most families.

Manufacturer Support

Foundation Grants

  • National Organization for Rare Disorders (NORD) patient assistance
  • HealthWell Foundation rare disease fund
  • Patient Access Network (PAN) Foundation

Counterforce Health helps patients and clinicians turn insurance denials into targeted, evidence-backed appeals. Their platform ingests denial letters and clinical notes to draft point-by-point rebuttals aligned to each plan's specific rules, pulling the right citations and clinical facts needed for approval.

Frequently Asked Questions

How long does UnitedHealthcare PA take in Texas? Standard prior authorization typically takes up to 24 hours, with automated approvals possible for qualifying cases. Appeals take 30 days for standard, 72 hours for expedited.

What if Dojolvi is non-formulary on my plan? Non-formulary drugs can still be covered with proper medical necessity documentation. Texas step therapy exception laws require UnitedHealthcare to approve exceptions when clinically appropriate.

Can I request an expedited appeal? Yes, if delay would seriously jeopardize your health. Your physician must provide a statement of urgency, and UnitedHealthcare must decide within 72 hours.

Does step therapy apply if I've tried alternatives outside Texas? Yes, prior therapy failures from any location count toward step therapy requirements. Include documentation from all previous providers.

What happens if I'm already on Dojolvi and change plans? Texas continuity of care laws typically provide a 90-day transition period where you maintain in-network benefits for ongoing specialty treatments.

Can I appeal directly to Texas if UnitedHealthcare denies? You must complete internal appeals first, then you can request external review through Texas Department of Insurance's IRO process.

From Our Advocates

"We've seen families succeed by getting their medical geneticist involved early in the PA process. One composite case involved a patient whose initial denial was quickly overturned after the specialist provided detailed genetic testing results and emphasized the lack of FDA-approved alternatives. The key was having all molecular confirmation ready before submitting the request." —Coverage advocacy experience

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 guidance. Coverage policies and appeal procedures may vary by plan type and can change over time.

For additional assistance with complex appeals, Counterforce Health provides specialized support for patients and clinicians navigating insurance coverage challenges for specialty medications.

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