Dojolvi (triheptanoin) prior authorization
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Defines prior authorization requirements and coverage criteria for Dojolvi (triheptanoin) for members with long-chain fatty acid oxidation disorders (LC-FAOD). Applies to UnitedHealthcare pharmacy benefit prior authorization processes.
No material clinical or coverage changes in this revision.
Coverage Criteria for Dojolvi (triheptanoin)
Initial Authorization
Approved when ALL of the following are met:
Authorization will be issued for 12 months
Reauthorization
Approved when ALL of the following are met:
Authorization will be issued for 12 months
Use of Dojolvi in combination with any other medium-chain triglyceride (MCT) product is explicitly excluded from approval. For both initial authorization and reauthorizationnot be receiving Dojolvi with other MCT products, and requests that propose combination therapy may be denied if this exclusion is not met.
Initial Therapy
Initial Therapy
Initial authorization requirements
12-month authorization
Continuation / Reauthorization Criteria
Continuation/Reauthorization
Reauthorization requirements
12-month reauthorization
Provider Actions, Documentation, and Denial Triggers
Prior authorization required — 12‑month approvals
Prior authorization is required for Dojolvi and will be approved only when all coverage criteria are met. Authorization will be issued for a 12‑month duration for both initial requests and reauthorizations.
Automation, reapproval, and utilization management
Automated approval and re‑approval processes may be used based on prior claim/medication history, diagnosis codes, and claim logic. Supply limits and/or medical necessity reviews may apply as part of utilization management.
- Automated approval/re-approval may rely on previous claim or medication history and ICD-10 diagnosis codes.
- Supply limits and medical necessity reviews may be enforced.
Required documentation for initial and reauthorization
Documentation must include molecular (genetic) confirmation of LC-FAOD for initial authorization and clinical documentation of a positive response to Dojolvi for reauthorization; medication/claim history may be used when automated approvals are applied.
- Initial authorization requires disease molecular confirmation (genetic testing).
- Reauthorization requires documentation of positive clinical response to therapy.
- Previous claim/medication history may be used when automated processes are applied.
Common denial triggers
Requests may be denied if required documentation or coverage conditions are not met — for example, missing molecular confirmation of LC-FAOD or requests where Dojolvi is used in combination with another MCT product.
- Absence of molecular (genetic) confirmation of LC-FAOD for initial requests.
- Lack of documentation of positive clinical response for reauthorization.
- Use of Dojolvi in combination with any other medium-chain triglyceride (MCT) product.
Definitions
Background
Dojolvi (triheptanoin) is a medium-chain triglyceride product used as a source of calories and fatty acids for patients with long-chain fatty acid oxidation disorders (LC-FAOD). Coverage is intended for pediatric and adult patients with a diagnosis of LC-FAOD and, per policy requirements, is contingent on meeting specified diagnostic criteria including molecular (genetic) confirmation of the disorder. Dojolvi is administered as a specialty nutritional therapy to address energy deficits associated with impaired long-chain fatty acid oxidation.
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