Download [INSERT_DATE] RE: Genetic Testing for Dilated Cardiomyopathy

[INSERT_DATE]
RE:
Genetic Testing for Dilated Cardiomyopathy with Cardiac Conduction Disease Letter of Medical
Necessity
Patient Name: [PATIENT_FULL_NAME]
DOB: [DATE_OF_BIRTH]
Subscriber/ID Number: [POLICY_NUMBER]
To Whom It May Concern:
I am writing on behalf of my patient to request authorization for genetic testing for Dilated Cardiomyopathy
with Cardiac Conduction Disease (DCM+CCD): CPT codes [INSERT CPT CODES] with diagnosis
code(s) of [INSERT_ICD10_CODES].
I suspect my patient has the life-threatening, inheritable heart disorder DCM+CCD, based on the following
medical history, signs and symptoms: [INSERT DETAILS, e.g., dilation of the left ventricle, diastolic
dysfunction, cardiac conduction system disease, family member(s) with DCM+CCD or DCM, syncope,
aborted sudden cardiac arrest, unexplained sudden cardiac death in relatives]
Dilated Cardiomyopathy (DCM) is the third most common cause of heart failure and the most
frequent cause of heart transplantation.1 CD-DCM is a particularly severe form of DCM and
predisposes patients to sudden cardiac death.2,3 Like DCM, CD-DCM is characterized by left ventricular
enlargement and reduced systolic function; however, significant conduction system disease can be the first
manifestation of this DCM subtype.2,3 Clinical investigations of cardiac conduction disease and DCM are
often non-specific and may not identify the underlying cause.1,2 This genetic test for CD-DCM is a critical
component of a comprehensive diagnostic workup and the results will guide treatment decisionmaking, including whether my patient may require an implantable cardioverter defibrillator. The test
results are also important for this patient’s family members: if a mutation is identified, then relatives at risk
for CD-DCM can be accurately identified by genetic testing and managed appropriately. The value of genetic
testing for CD-DCM has been documented extensively in the medical literature, the American College of
Cardiology, American Heart Association, European Society of Cardiology, Heart Failure Society of
America, Heart Rhythm Society, and European Heart Rhythm Association have issued evidence-based
practice guidelines recommending genetic testing for all DCM patients and their potentially at-risk family
members.4-6
The FAMILION CD-DCM test is an accurate test for patients suspected to have CD-DCM, and is performed
in a CLIA-certified laboratory that meets all applicable state and federal guidelines. The results of this test
are medically necessary to guide treatment of this patient. Thank you for your time and consideration of
my request. Please contact me if you wish to discuss my patient’s treatment plan or require additional
information.
Respectfully,
[INSERT_PHYSCIAN_NAME,
ADDRESS,
AND_PHONE_NUMBER]
References: 1) Luk A, Ahn E, Soor GS, et al. Dilated cardiomyopathy: a review. J Clin Pathol. 2009;62:219-25 2) Hershberger RE,
Cowan J, Morales A. LMNA-Related Dilated Cardiomyopathy. In: GeneReviews at GeneTests: Medical Genetics Information
Resource. University of Washington, Seattle. 1997-2009 3) Pasotti M, Klersy C, Pilotta A et al. Long-Term Outcome and Risk
Stratification in Dilated Cardiomyoapthies. J of the Amer College of Cardiology. 2008; 52: 1250-60. 4) Zipes DP, Camm AJ,
Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention
of Sudden Cardiac Death. Circulation. 2006;114:e385-484. 5) Hershberger RE, Lindenfeld J, Mestroni L, et al. Genetic evaluation of
cardiomyopathy – a heart failure society of America practice guideline. J Card Fail. 2009;5:464. 6) Ackerman MJ, Priori SG,
Willems S, et al. HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and
cardiomyopathies. Heart Rhythm. 2011;8:1308-39.