By Counterforce Health Team in Dojolvi (triheptanoin) —

Work With Your Doctor to Get Dojolvi (Triheptanoin) Approved by Blue Cross Blue Shield in Virginia: Complete PA and Appeals Guide

Quick Answer: Getting Dojolvi Approved by Blue Cross Blue Shield in Virginia

Blue Cross Blue Shield requires strict prior authorization for Dojolvi (triheptanoin), mandating molecular confirmation of LC-FAOD, specialist supervision, and detailed clinical documentation. Your fastest path to approval: 1) Confirm genetic testing proves LC-FAOD, 2) Work with a metabolic specialist to complete PA documentation, 3) Submit comprehensive medical necessity letter via BCBS provider portal. If denied, Virginia's State Corporation Commission provides external review using Form 216-A within 120 days.

Table of Contents

  1. Set Your Goal: Understanding BCBS Requirements
  2. Preparing for Your Doctor Visit
  3. Building Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Supporting Peer-to-Peer Reviews
  6. After Your Visit: Documentation
  7. Respectful Persistence and Follow-Up
  8. Virginia Appeals Process
  9. Common Denial Reasons & Solutions
  10. FAQ

Set Your Goal: Understanding BCBS Requirements

Working with your doctor to get Dojolvi approved by Blue Cross Blue Shield in Virginia requires meeting specific clinical and administrative criteria. Here's what approval requires and how you'll partner with your healthcare provider.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Molecular confirmation Genetic testing proving LC-FAOD Lab reports showing CPT2, ACADVL, HADHA, or HADHB mutations
Specialist supervision Metabolic geneticist or endocrinologist oversight Provider credentials and consultation notes
No concurrent MCT use Discontinue all MCT oil products Medication reconciliation documentation
Dosing limits ≤35% of daily caloric intake Dietitian calculations and treatment plan
Prior authorization Required for all BCBS plans BCBS provider portal

Your Partnership Strategy

Your role is to provide comprehensive clinical history and ensure all documentation reaches your doctor. Your provider's role is to compile medical necessity justification and submit the prior authorization. Success depends on thorough preparation and clear communication between you and your healthcare team.

Note: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into targeted, evidence-backed appeals by analyzing denial letters and crafting point-by-point rebuttals aligned to each plan's specific rules.

Preparing for Your Doctor Visit

Come to your appointment with organized information that demonstrates medical necessity for Dojolvi. This preparation saves time and ensures nothing important gets missed.

Symptom Timeline Documentation

Create a chronological record of your LC-FAOD symptoms and hospitalizations:

  • Energy crises: Document episodes of severe fatigue, muscle weakness, or hypoglycemia
  • Cardiac symptoms: Note any cardiomyopathy, arrhythmias, or cardiac monitoring results
  • Exercise intolerance: Record limitations in physical activity and recovery times
  • Emergency visits: List dates, symptoms, and treatments for metabolic decompensation

Prior Treatment History

Compile detailed records of previous therapies:

  • MCT oil use: Dosing, duration, effectiveness, and any side effects
  • Dietary modifications: Low-fat diets, carnitine supplementation, fasting avoidance protocols
  • Failed treatments: Document inadequate response or intolerance to standard care
  • Current medications: List all supplements and prescription drugs

Functional Impact Assessment

Prepare specific examples of how LC-FAOD affects your daily life:

  • Work or school limitations
  • Exercise restrictions
  • Dietary challenges and social impact
  • Quality of life changes since diagnosis

Building Your Evidence Kit

Gather comprehensive documentation that supports your Dojolvi request. This evidence kit becomes the foundation for your medical necessity letter.

Essential Laboratory Evidence

Genetic Testing Results

  • Molecular confirmation of LC-FAOD with specific gene mutations
  • Acylcarnitine profiles showing characteristic elevations
  • Enzyme activity assays if available

Clinical Monitoring Data

  • Echocardiograms documenting cardiomyopathy
  • Exercise stress tests showing limitations
  • Laboratory values during metabolic crises

Published Guidelines and References

Your doctor will need current medical literature supporting Dojolvi use:

  • FDA approval documentation for LC-FAOD treatment
  • Clinical trial data demonstrating efficacy
  • Metabolic specialty society recommendations

Treatment History Summary

Create a one-page summary including:

  • Diagnosis date and confirming tests
  • All prior therapies with dates and outcomes
  • Current symptoms despite standard care
  • Specialist consultations and recommendations

Medical Necessity Letter Structure

Work with your doctor to ensure the medical necessity letter includes all required elements for BCBS approval.

Core Letter Components

Patient Demographics and Diagnosis

Patient: [Name, DOB, BCBS ID]
Diagnosis: Molecularly confirmed LC-FAOD
Gene mutation: [Specific variant, e.g., CPT2 c.338C>T]
ICD-10: E71.310 (Long chain acyl CoA dehydrogenase deficiency)

FDA Indication Statement "Dojolvi (triheptanoin) is FDA-approved as a source of calories and fatty acids for pediatric and adult patients with molecularly confirmed long-chain fatty acid oxidation disorders."

Clinical Rationale

  • Explain LC-FAOD pathophysiology and energy metabolism defects
  • Document failed or inadequate response to conventional therapy
  • Describe current symptoms and functional limitations
  • Justify Dojolvi's unique mechanism of action

Treatment Plan Details

  • Calculated dose as percentage of daily caloric intake (≤35%)
  • Dosing schedule (minimum 4 times daily with meals)
  • Monitoring plan for efficacy and safety
  • Discontinuation of concurrent MCT products

Supporting Documentation Checklist

  • Genetic test results
  • Specialist consultation notes
  • Prior therapy summary with outcomes
  • Current symptom assessment
  • Dietitian evaluation and caloric calculations
  • Cardiac monitoring results if applicable

Supporting Peer-to-Peer Reviews

If BCBS requests a peer-to-peer review, help your doctor prepare for this important conversation with the plan's medical director.

Preparation Strategy

Availability Windows Provide your doctor with your preferred times for the peer-to-peer call so they can coordinate scheduling with BCBS.

Case Summary for Provider Create a concise one-page summary your doctor can reference:

  • Key clinical points supporting medical necessity
  • Specific prior treatment failures
  • Current functional limitations
  • Expected outcomes with Dojolvi therapy

Key Discussion Points

Your doctor should be prepared to discuss:

  • Molecular confirmation of LC-FAOD diagnosis
  • Inadequacy of current dietary management
  • Risk of continued metabolic decompensation without treatment
  • Dojolvi's FDA approval and clinical trial evidence

After Your Visit: Documentation

Ensure proper documentation and follow-up after your appointment.

What to Save

  • Copy of the prior authorization submission
  • Medical necessity letter
  • All supporting clinical documentation
  • BCBS confirmation of receipt
  • Reference number for your PA request

Portal Communication

Use your healthcare provider's patient portal to:

  • Request copies of submitted documentation
  • Ask for updates on PA status
  • Provide additional information if requested by BCBS
  • Schedule follow-up appointments
From our advocates: "We've seen cases where patients who maintained organized records and regular communication with their care team had faster approval times. Keep a simple log of all interactions with both your doctor's office and BCBS—it helps everyone stay on the same page when questions arise."

Respectful Persistence and Follow-Up

Maintain appropriate follow-up without overwhelming your healthcare team.

Update Cadence

Week 1-2: Allow time for initial BCBS review (standard timeframe is 5-10 business days)

Week 3: Contact your doctor's office if no response from BCBS

Week 4+: If still pending, request peer-to-peer review or consider appeal preparation

Escalation Steps

  1. Provider office follow-up: Ask staff to check PA status via BCBS provider portal
  2. Member services call: Contact BCBS directly using number on your insurance card
  3. Supervisor request: If initial representative cannot help, politely ask for supervisor
  4. Appeal preparation: Begin gathering documentation for formal appeal if needed

Working with Counterforce Health can streamline this process by analyzing your specific denial and crafting targeted appeals that address BCBS's exact criteria.

Virginia Appeals Process

If BCBS denies your Dojolvi request, Virginia provides robust appeal rights through the State Corporation Commission Bureau of Insurance.

Internal Appeals First

Complete BCBS's internal appeal process before pursuing external review:

  • Submit appeal within 180 days of denial notice
  • Include additional clinical documentation
  • Request expedited review if clinically urgent

External Review Process

Eligibility Requirements

  • Completed internal appeals process
  • Denial based on medical necessity or experimental/investigational status
  • Virginia-issued insurance plan or opted-in self-funded plan

Filing External Review

  • Submit Form 216-A within 120 days of final internal denial
  • Include denial letter (do not send medical records initially)
  • Use Form 216-B if filing as authorized representative

Contact Information

  • Mail: P.O. Box 1157, Richmond, VA 23218
  • Fax: 804-371-9915
  • Email: [email protected]
  • Phone: 1-877-310-6560

Timeline and Process

Standard Review: 45 days for decision Expedited Review: 72 hours (requires Form 216-C physician certification)

The Bureau assigns your case to an Independent Review Organization (IRO) with relevant medical expertise. The IRO's decision is binding on BCBS.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing molecular confirmation Submit genetic testing reports with specific mutations
Concurrent MCT use Document discontinuation of all MCT products
Lack of specialist supervision Provide metabolic geneticist consultation notes
Insufficient prior therapy documentation Compile detailed treatment history with outcomes
Dosing concerns Include dietitian calculations showing ≤35% DCI
Not medically necessary Strengthen clinical rationale with current symptoms

FAQ

How long does BCBS prior authorization take in Virginia? Standard review is 5-10 business days. Expedited review for urgent cases is typically 72 hours.

What if Dojolvi is non-formulary on my BCBS plan? Request a formulary exception with medical necessity documentation. Non-formulary drugs can still be covered with appropriate justification.

Can I request an expedited appeal in Virginia? Yes, if your physician certifies that delay could jeopardize your health using Form 216-C for external review.

Does step therapy apply if I've tried treatments outside Virginia? Treatment history from any location counts toward step therapy requirements. Provide documentation from all previous providers.

What counts as molecular confirmation for LC-FAOD? Genetic testing showing pathogenic variants in CPT2, ACADVL, HADHA, HADHB, or other LC-FAOD genes. Biochemical testing alone may not be sufficient.

How much does Dojolvi cost without insurance? Cash prices typically range from $5,857-$6,365 per 500mL bottle. Ultragenyx offers patient assistance programs for eligible patients.

Can my primary care doctor prescribe Dojolvi? While technically possible, BCBS typically requires specialist supervision from a metabolic geneticist or endocrinologist for approval.

What happens if external review upholds the denial? The IRO decision is final and binding. You may consider legal consultation or explore alternative funding sources.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical advice. Always consult with your healthcare provider and insurance plan for specific coverage decisions. Insurance policies and state regulations may change; verify current requirements with official sources.

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