Download Glucose-6-Phosphate Dehydrogenase (G6PD) deficiency

[Date]
[Insurance Company]
[Address 1]
[Address 2]
[City State Zip]
Re: [Patient Name]
Insurance ID: [ID #]
DOB: XX/XX/XXXX
To whom it may concern,
I am writing on behalf of my patient to recommend DNA testing for Glucose-6-Phosphate Dehydrogenase
(G6PD) deficiency. G6PD is an enzyme that protects red blood cells from oxidative stress. G6PD deficiency is an
X-linked recessive disorder that mainly affects males, although carrier females may be affected as well. It is
variably characterized by neonatal jaundice, acute hemolytic anemia in response to oxidative stress, and chronic
nonspherocytic hemolytic anemia in the absence of oxidative stressors. Residual enzyme levels vary even in
symptomatic individuals and are not necessarily predictive of disease severity. Thus, enzyme activity estimates
are helpful, but not sufficient for diagnosis or determination of carrier status. At-risk individuals should be
identified by molecular genetic testing.
Individuals diagnosed with G6PD deficiency are at risk for acute hemolytic reactions that may be triggered by
infection, exposure to oxidative drugs, or ingestion of fava beans. Knowledge of mutation status enhances patient
care by allowing the patient and their healthcare providers to avoid agents that may trigger a hemolytic event, and
allow early diagnosis of such events which may prevent more serious complications.
This patient is suspicious for G6PD based on [describe symptomatology] and/or family history [describe]. If a
germline mutation is identified in this patient, his/her recommended screening and medical management will be
significantly altered.
Please note that this test is performed for clinical management in a laboratory that is CLIA approved for high
complexity testing.
Authorization should be obtained for:
Test name: [Test name]
Facility: ARUP Laboratories
CPT codes: 81479
Diagnosis code: [Diagnosis code]
Thank you for your time and attention to this matter.
Sincerely,
[Name of Ordering Physician]
From www.aruplab.com
Revision 1
Created: xx/xx/xxxx
References:
Minucci A, Giardina B, Zuppi C, Capoluongo E. Glucose-6-phosphate dehydrogenase laboratory assay: How, when, and why? IUBMB
Life. 2009 Jan;61(1):27-34.
From www.aruplab.com
Revision 1
Created: xx/xx/xxxx