Download [INSERT_DATE] RE: Genetic Testing for CPVT Letter of Medical

[INSERT_DATE]
RE:
Genetic Testing for CPVT 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 Catecholaminergic
Polymorphic Ventricular Tachycardia (CPVT): CPT codes [INSERT CPT CODES] with diagnosis code(s) of
[INSERT_ICD10_CODES].
I suspect my patient has the life-threatening, inheritable arrhythmia disorder known as CPVT, based on the
following medical history, signs and symptoms: [INSERT DETAILS, e.g., stress-induced reproducible
ventricular arrhythmias, bi-directional ventricular tachycardia, prominent U waves, syncope, aborted sudden
cardiac arrest, family member(s) with CPVT, unexplained sudden cardiac death in family members]
CPVT is characterized by cardiac arrhythmias triggered by exercise or acute emotional stress, and is associated
with a high risk for sudden cardiac death.1 The diagnosis and management of CPVT patients pose several
challenges. The clinical presentation of CPVT is often similar to another cardiac channelopathy called long QT
syndrome (LQTS). However, unlike some forms of LQTS, anti-arrhythmic drug therapies are ineffective in
approximately half of CPVT patients and they remain at high risk for sudden death. The diagnostic challenges,
the inability of drugs to provide reliable protection against life-threatening cardiac events, and the high lethality
associated with this disease is why CPVT is regarded as one of the most dangerous inherited arrhythmogenic
disorders. Thus, an accurate diagnosis of CPVT is imperative for proper management. This genetic test is a
critical component of a comprehensive diagnostic workup and the results will guide treatment decisionmaking, including whether my patient can be managed pharmacologically or may require an implanted
cardiac defibrillator. The test results are also important for this patient’s family members: if a mutation is
identified, then relatives at risk for CPVT can be accurately identified by genetic testing and managed
appropriately. The value of genetic testing for CPVT has been documented extensively in the medical literature,
and the American College of Cardiology, American Heart Association, European Society of Cardiology, Heart
Rhythm Society, and European Heart Rhythm Association have issued evidence-based practice guidelines
recommending genetic testing for all CPVT patients and their potentially at-risk family members.2-4
The FAMILION CPVT test is an accurate test for patients suspected to have CPVT, and is performed in a CLIAcertified 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) Napolitano C, Priori SG. Diagnosis and treatment of catecholaminergic polymorphic ventricular tachycardia. Heart
Rhythm. 2007;4:675-8. 2) 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. 3) 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. 4) Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus statement on the
diagnosis and management of patients with inherited primary arrhythmia syndromes. Heart Rhythm. 2013;10:1932-63.