Download Letter of Medical Necessity Test Code 1975 <<Today`s Date

Letter of Medical Necessity Test Code 1975
<<Today’s Date>>
<<Insurance Company Name>>
<<Address 1>>
<<Address 2>>
<<City, State ZIP>>
Regarding: <<Patient full name>>
DOB: <<MM/DD/YYYY>>
Subscriber ID: <<Member ID#>>
Group ID: <<Group ID#>>
Re: Request for prior authorization and coverage for Hereditary Colorectal Cancer genetic testing. Billing is
through <<billing institution>> with testing performed at PreventionGenetics, LLC. CPT codes for
PreventionGenetics test code #1975 include: 81408, 81479 (x12), 81295, 81297, 81298, 81300, 81406
(x3), 81321, 81323, 81405 (x3), 81201, 81203, 81292, 81294, 81317, 81319, 81404 and 81403. . The ICD
10 code(s) associated with the patient’s diagnosis include <<ICD code(s)>>.
Hereditary Colorectal Cancer
As many as 5% of colorectal cancer diagnoses are thought to be associated with a hereditary predisposition . Hereditary cancers are caused by germline mutations in multiple different genes which
significantly increase an individual’s risk to develop cancer. Individuals with mutations in inherited
predisposition genes tend to develop cancer at earlier ages, often with bilateral and / or multifocal tumors,
which can also occur in less frequently affected genders (i.e.: male breast cancer). Families with hereditary
cancer syndromes generally have several family members affected with cancer across multiple
generations. Although individual mutated genes can be associated with an increased risk for specific
cancers (i.e.: MLH1 and MSH2 with colorectal cancer) there are often multiple additional cancers seen with
lower frequency (i.e.: uterine, ovarian, gastric, hepatobiliary, urinary tract, small bowel, sebaceous
neoplasms, pancreatic and brain cancer in Lynch Syndrome families). Considering that multiple cancers,
including ovarian, pancreatic, melanoma, kidney, breast, uterine, colorectal, sarcoma, brain, leukemia,
gastric, thyroid and prostate cancer have been linked with several different cancer predisposition genes,
there is significant complexity in choosing a single gene to target for analysis.
1,2
Colorectal Cancer (CRC) inherited diseases include Lynch Syndrome, Hereditary Diffuse Gastric Cancer,
Juvenile Polyposis Syndrome, PTEN Hamartoma Syndrome, Familial Adenomatous Polyposis, PeutzJeghers Syndrome, Li-Fraumeni Syndrome, CHEK2- related cancers, MUTYH-Associated Polyposis,
Ataxia-Telangiectasia, Bloom Syndrome and Mosaic Variegated Aneuploidy Syndrome. Each of these
conditions can be associated with multiple cancer diagnoses. This overlap can result in falsely reassuring
results when the incorrect target gene is selected. Therefore the assessment of multiple genes associated
with a high risk for hereditary colorectal cancers can be useful in determining personal or familial risks .
Multigene testing in this setting is likely to alter near-term cancer risk assessment and management
recommendations for mutation-affected individuals across a broad spectrum of cancer predisposition
genes.”
3
4
Diagnosis of an individual with a hereditary cancer syndrome has significant effects on medical
management. Gene specific medical management guidelines demonstrate the clinical utility of hereditary
cancer predisposition testing. Many of the cancer syndromes covered in the Colorectal Cancer testing
panel have published clinical management guidelines which can help to reduce the risk of morbidity and
mortality in patients affected with or at risk for hereditary cancer syndromes. Risk reduction strategies
outlined in NCCN management guidelines include surgical interventions (ie: prophylactic colectomy,
gastrectomy, mastectomy, hysterectomy and salpingo-oopherectomy); increased surveillance at younger
ages (i.e. colonoscopy / sigmoidoscopy, endoscopy, abdominal MRI / CT, mammography/ breast MRI and
ultrasound, clinical and self-breast exams, prostate screening) and consideration of chemo preventive
pharmaceuticals.
5
Personal History
<<Personal Medical History: Include details of patient’s relevant medical history>>
Family History
<<Family History: Include list of relevant family history information if applicable. Appropriate risk
assessment models or limited history should be noted >>
Based on published NCCN and ACMG guidelines, the personal and family history of this patient warrants
analysis of genes known to be associated with hereditary colorectal cancer The Colorectal Cancer
NextGen Sequencing (NGS) and Deletion/Duplication Panel analyzes 17 genes which are associated with
a high risk of hereditary colon cancer including, APC, ATM, BLM, BMPR1A, BUB1B, CDH1, CHEK2,
EPCAM, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, SMAD4, STK11, and TP53. Many hereditary
cancer syndromes involving colorectal cancers have overlapping clinical features. Therefore, analysis of a
panel of genes known to be associated with colorectal cancers is the most cost-effective and
comprehensive testing option.
5,6.
The laboratory providing the genetic testing is PreventionGenetics, LLC, (Tax ID: 83 0343803) who is a
sponsor of Pediatric Lab Utilization Guidance Services (PLUGS®). PreventionGenetics is committed to
providing comprehensive, high quality, and affordable genetic testing that adds value to patient
care. Through utilization management strategies at PreventionGenetics, over 1.3 million healthcare dollars
are saved annually.
I am hopeful that we can work together for <<Mr/Mrs/Ms/Miss patient’s last name’s>> benefit. Please
contact me at <<Phone #>> with the result of this prior authorization and/or if you need additional
information.
Sincerely,
<<Name, credentials>>
<<Title>>
<<Institution>>
References:
1.
2.
3.
4.
5.
Jasperson, et al. Gastroenterology, 2010. 138(6): 2044-2058
Sameer, et al. Front Oncol, 2013. 3:114
Foulkes. New England Journal of Medicine. 2008; 359: 2143-2153
Desmond et al. JAMA Oncol. 2015;1(7):943-951
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines ). Genetic/Familial High-Risk
Assessment: Colorectal. Version 2.2015, 10/07/2015.
Hedge, et al. Genet Med, 2014. 16(1):101-116
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