By Counterforce Health Team in Dojolvi (triheptanoin) —

Work With Your Doctor to Get Dojolvi (Triheptanoin) Covered by Humana in Pennsylvania: Complete Provider Partnership Guide

Answer Box: Getting Dojolvi Covered by Humana in Pennsylvania

Eligibility: Humana requires molecular confirmation of LC-FAOD via genetic testing, specialist oversight, and discontinuation of other MCT products. Fastest path: Schedule an appointment with your metabolic specialist to gather genetic test results, treatment history, and submit a comprehensive prior authorization with medical necessity letter. First step today: Contact your doctor's office to request your LC-FAOD genetic testing results and schedule a visit to discuss Dojolvi coverage strategy. Pennsylvania's external review program overturns ~50% of denials if initial authorization fails.

Table of Contents

  1. Set Your Coverage Goal
  2. Prepare for Your Doctor Visit
  3. Build Your Evidence Kit
  4. Medical Necessity Letter Structure
  5. Support Peer-to-Peer Review
  6. Document Everything After Your Visit
  7. Practice Respectful Persistence
  8. Pennsylvania Appeals Process
  9. Common Denial Reasons & Solutions
  10. FAQ

Set Your Coverage Goal

Working with your doctor to get Dojolvi (triheptanoin) approved by Humana requires understanding exactly what the insurer needs to see. Humana's prior authorization requirements are strict but predictable.

Coverage Requirements at a Glance

Requirement What It Means Where to Find It
Molecular confirmation Genetic test proving LC-FAOD diagnosis Lab reports from geneticist/metabolic specialist
Specialist prescriber Metabolic specialist, geneticist, or endocrinologist Provider credentials on prescription
MCT discontinuation Stop other medium-chain triglyceride products Documentation in medical records
Treatment history Proof that standard dietary therapy was insufficient Hospitalization records, nutrition consult notes
Dosing plan Detailed caloric intake calculation (up to 35% DCI) Registered dietitian assessment

Your partnership with your healthcare team is crucial because LC-FAOD requires specialist management to prevent life-threatening metabolic crises.

Prepare for Your Doctor Visit

Come to your appointment prepared with a clear timeline and comprehensive symptom history. Your doctor needs specific details to craft a compelling medical necessity case.

Symptom Timeline Checklist

Before your visit, document:

  • Metabolic episodes: Dates of hospitalizations, emergency room visits, or severe hypoglycemic events
  • Current symptoms: Muscle weakness, exercise intolerance, cardiomyopathy symptoms, growth issues (if pediatric)
  • Functional impact: How LC-FAOD affects work, school, daily activities, and quality of life
  • Dietary compliance: Evidence you've followed low long-chain fat diet recommendations

Treatment History Documentation

Gather records showing:

  • Previous MCT oil supplementation and outcomes
  • Cornstarch therapy trials (if used)
  • Dietary modifications attempted
  • Specialist consultations and recommendations
  • Any adverse reactions to current treatments
Tip: Request copies of all LC-FAOD related medical records at least one week before your appointment. This gives your doctor time to review your complete history.

Build Your Evidence Kit

Your doctor will need comprehensive documentation to support the prior authorization request. Help them gather the strongest possible evidence package.

Essential Laboratory Evidence

  • Genetic testing results: DNA sequencing confirming LC-FAOD mutations (ACADVL, HADHA, HADHB, CPT1A, CPT2, or SLC22A5 genes)
  • Acylcarnitine profile: Tandem mass spectrometry results showing disease-specific patterns
  • Metabolic panels: Evidence of hypoglycemia, elevated creatine kinase, or liver enzyme abnormalities during episodes

Clinical Guidelines and References

Your doctor should reference published treatment guidelines that support Dojolvi use when standard dietary therapy proves insufficient. Key citations include:

  • FDA approval documentation for Dojolvi in LC-FAOD
  • Clinical trial data showing improved cardiac function and reduced hospitalizations
  • Metabolic specialist society recommendations for triheptanoin therapy

Medication History Summary

Document all previous treatments attempted:

  • MCT oil products (brands, doses, duration, outcomes)
  • Dietary supplements and modifications
  • Emergency protocols used during metabolic crises
  • Reasons for treatment failures or intolerances

Medical Necessity Letter Structure

A well-structured medical necessity letter significantly improves approval odds. Work with your doctor to ensure all key elements are included.

Letter Components Checklist

Patient Background:

  • Confirmed LC-FAOD diagnosis with genetic testing details
  • Age at diagnosis and current clinical status
  • Frequency and severity of metabolic episodes

Clinical Rationale:

  • Explanation of why standard dietary management is insufficient
  • Documentation of persistent symptoms despite optimal care
  • Risk of continued metabolic instability without Dojolvi

Treatment Plan:

  • Specific Dojolvi dosing strategy (percentage of daily caloric intake)
  • Integration with existing dietary management
  • Monitoring plan and follow-up schedule

Supporting Evidence:

  • References to clinical guidelines and FDA labeling
  • Peer-reviewed studies demonstrating Dojolvi efficacy
  • Specialist consultation notes supporting medical necessity
From our advocates: We've seen the strongest approvals when providers include specific quotes from FDA labeling about Dojolvi being "indicated as a source of calories and fatty acids for the treatment of pediatric and adult patients with molecularly confirmed long-chain fatty acid oxidation disorders." This regulatory language carries significant weight with payers.

Counterforce Health helps healthcare teams structure these letters effectively by analyzing payer policies and identifying the specific documentation requirements that lead to faster approvals.

Support Peer-to-Peer Review

If Humana initially denies coverage, your doctor can request a peer-to-peer review with Humana's medical director. Your preparation can make this conversation more effective.

Peer-to-Peer Preparation

Help your doctor prepare by providing:

Availability Windows:

  • Offer flexible scheduling to accommodate the peer-to-peer call
  • Provide multiple time slots when you can be available for discussion

Concise Case Summary:

  • One-page summary of your diagnosis, treatment history, and current symptoms
  • Clear explanation of why Dojolvi is medically necessary
  • Documentation of failed alternative therapies

Script for Provider Peer-to-Peer Request

Your doctor's office can use this template when calling Humana:

"I'm requesting a peer-to-peer review for [patient name] regarding prior authorization for Dojolvi. This patient has molecularly confirmed LC-FAOD with genetic testing and continues to experience metabolic instability despite optimal dietary management. I have comprehensive documentation including specialist consultations and treatment history showing medical necessity for triheptanoin therapy."

Document Everything After Your Visit

Maintain detailed records of all interactions with your healthcare team and Humana throughout the approval process.

What to Save

  • Provider portal messages: Screenshot all communications about your prior authorization
  • Phone call logs: Date, time, representative name, and summary of each conversation
  • Submitted documents: Copies of all forms, letters, and supporting documentation
  • Timeline tracking: Record submission dates and expected response timeframes

Portal Communication Tips

When messaging your doctor's office through patient portals:

  • Use clear, specific subject lines ("Dojolvi PA Update" or "Additional Documentation Needed")
  • Include relevant dates and reference numbers
  • Attach any new documentation or insurance communications
  • Request read receipts when possible

Practice Respectful Persistence

Getting specialty drug coverage approved often requires multiple touchpoints. Maintain professional communication while advocating effectively for your needs.

Update Cadence Guidelines

Week 1-2: Allow normal processing time without additional contact Week 3: Send polite status inquiry to your doctor's office Week 4+: Request escalation to prior authorization specialist or nurse case manager

Escalation Script Template

"I wanted to follow up on the Dojolvi prior authorization submitted [date]. Given my LC-FAOD diagnosis and history of metabolic episodes, timely access to this medication is crucial for preventing serious complications. Could you please check the status and let me know if any additional documentation is needed?"

Pennsylvania Appeals Process

If Humana denies your initial request, Pennsylvania offers robust appeals options with favorable success rates.

Internal Appeals Timeline

  • File within: 65 days of denial notice
  • Humana decision: 7 days for Part D drug appeals
  • Expedited option: 72 hours if delay could jeopardize health

Pennsylvania External Review

Pennsylvania's Independent External Review Program has overturned approximately 50% of appealed denials in its first year.

Process:

  1. Complete Humana's internal appeal first
  2. Request external review within 4 months of final denial
  3. Submit additional supporting documentation within 15 days
  4. Independent physician reviewers make binding decision within 45 days

Counterforce Health specializes in turning insurance denials into successful appeals by identifying the specific evidence gaps that led to initial denials and crafting targeted rebuttals aligned with payer policies.

Common Denial Reasons & Solutions

Denial Reason How to Overturn
Missing molecular confirmation Submit genetic testing results with clear LC-FAOD mutation identification
Concurrent MCT use Provide documentation showing discontinuation of other MCT products
Lack of specialist oversight Include consultation notes from metabolic specialist or geneticist
Insufficient treatment history Document failed dietary interventions with hospitalization records
Quantity limits exceeded Submit dietitian calculations showing medical necessity for prescribed dose

FAQ

How long does Humana prior authorization take in Pennsylvania? Standard requests typically receive decisions within 7-30 days depending on plan type. Expedited requests are decided within 72 hours when clinical urgency is documented.

What if Dojolvi is non-formulary on my Humana plan? Request a formulary exception with medical necessity documentation. Humana's exception process allows coverage for non-formulary medications when medically necessary.

Can I request an expedited appeal if denied? Yes, if waiting could seriously jeopardize your health. Your doctor must document the clinical urgency in the expedited request.

Does Pennsylvania's external review apply to Medicare Advantage plans? Medicare Advantage appeals follow federal procedures rather than Pennsylvania's state external review process. However, you can file complaints with Pennsylvania's Insurance Department for procedural issues.

What documentation proves LC-FAOD molecular confirmation? Genetic testing reports showing pathogenic mutations in relevant genes (ACADVL, HADHA, HADHB, CPT1A, CPT2, SLC22A5) from a certified laboratory.

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

Sources & Further Reading

This guide provides educational information and is not medical advice. Always consult with your healthcare provider about your specific situation. For additional help with insurance appeals in Pennsylvania, contact the Pennsylvania Insurance Department at 1-877-881-6388.

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