Download medical necessity letter

LETTER OF MEDICAL NECESSITY FOR BRCA1/BRCA2 GENETIC TESTING
Date:
Date of service/claim
To:
Utilization Review Department
Insurance Company Name, Address, City, State
Re:
Patient Name, DOB, ID #
ICD-9 Codes: (list codes)
This letter is to urge you to provide coverage for medically-indicated BRCA1/BRCA2 genetic testing
for the above named patient. The personal and/or family history reported on the test requisition
form raises significant concern for hereditary breast and ovarian cancer syndrome and indicates a
reasonable probability of detecting a BRCA1/BRCA2 mutation in the patient.
Women who carry a BRCA1 or BRCA2 mutation have up to an 85% chance of developing breast
cancer (compared to 12% in the general population), a 40-60% risk for a second primary
(ipsilateral or contralateral) breast cancer, and a 15-45% chance of developing ovarian cancer
(compared to 1.6% in the general population.) Men who carry a BRCA1 or BRCA2 mutation have an
elevated risk for breast and prostate cancer.
The rationale for testing is the presence of a BRCA mutation places this patient at a substantially
increased risk for developing cancer and thus would influence our care recommendations
significantly. An aggressive approach to reduce the risk of cancer is indicated in individuals who
carry a BRCA1 or BRCA2 mutation. If a mutation is identified, we would recommend high-risk
management to reduce the patient’s risk of developing an advanced stage cancer and subsequently
dying of the disease. As such, I am ordering this genetic test as medically necessary care and affirm
that the patient has provided informed consent for genetic testing.
Full-gene sequencing and deletion/duplication analysis of BRCA1 and BRCA2 is warranted,
consistent with guidelines established by the American Society of Clinical Oncologists (ASCO) and
the National Comprehensive Cancer Network (NCCN). These services are recognized as standard of
care in the community (as evidenced by coverage by most major indemnity plans).
Please contact me if I can provide you with additional information.
Sincerely,
Ordering Clinician Name (Signature Provided on Test Requisition Form)
Test Details
CPT codes:
81211x1, 81213x1
Laboratory:
Ambry Genetics Corporation (TIN 33-0892453 / NPI 1861568784), a CAP-accredited and
CLIA-certified laboratory located at 15 Argonaut, Aliso Viejo, CA 92656