Download [INSERT_DATE] RE: Genetic Testing for Dilated Cardiomyopathy

[INSERT_DATE]
RE:
Genetic Testing for Dilated Cardiomyopathy 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
(DCM): 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, based on the following medical
history, signs and symptoms: INSERT DETAILS, e.g., dilation of the left ventricle, diastolic dysfunction,
family member(s) with DCM, syncope, aborted sudden cardiac arrest, unexplained sudden cardiac death
in relatives]
DCM predisposes patients to heart failure and sudden cardiac death, and is characterized by ventricular
chamber enlargement and a reduction in contractile performance.1 DCM is the third most common cause of
heart failure and the most frequent cause of heart transplantation.1 For many DCM patients, the cause of
disease is unidentified and referred to as idiopathic DCM; in fact, 20-50% of idiopathic DCM is now known
to be genetic.2 Clinical investigations of DCM are often non-specific and may not identify the underlying
cause.1,2 DCM presentations are similar, regardless of the underlying cause, but can differ greatly in their
clinical course, outcomes, and management. This genetic test for DCM is a critical component of a
comprehensive diagnostic workup and the results will guide treatment decision-making, including
whether my patient 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 DCM can be accurately
identified by genetic testing and managed appropriately. The value of genetic testing for DCM has been
documented extensively in the medical literature, and 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.3-5
The FAMILION DCM test is an accurate test for patients suspected to have 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,
Kushner JD, Parks SB. Dilated Cardiomyopathy Overview. In: GeneReviews at GeneTests: Medical Genetics Information Resource.
University of Washington, Seattle. 1997-2009 3) 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:e385484. 4) 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. 5) 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.