Download [INSERT_DATE] RE: Genetic Testing for Arrhythmogenic Right

[INSERT_DATE]
RE:
Genetic Testing for Arrhythmogenic Right Ventricular 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 Arrhythmogenic Right
Ventricular Cardiomyopathy (ARVC): CPT codes [INSERT CPT CODES] with diagnosis code(s) of
[INSERT_ICD-10 CODES].
I suspect my patient has the life-threatening, inheritable heart disorder ARVC, based on the following
medical history, signs and symptoms: [INSERT DETAILS, e.g., dilation of the right ventricle, dysfunction
of the right ventricle, fibrofatty tissue infiltration, conduction abnormalities, arrhythmias, syncope,
aborted sudden cardiac arrest, family member(s) with ARVC, unexplained sudden cardiac death in
relatives].
ARVC is a progressive heart disease that predisposes patients to sudden cardiac death and is characterized by
replacement of heart muscle tissue with fatty and fibrous tissue.1 Approximately 40% of ARVC patients
experience sudden cardiac death as their first clinical manifestation.1,2 However, with early diagnosis and
appropriate treatment, most ARVC patients have an excellent prognosis.1 Treatment often includes
implanting a cardioverter defibrillator.1,2 Making an accurate diagnosis of ARVC is challenging, especially
during early in the course of the disease, since no single diagnostic test is sufficient, and other generally
benign conditions can present similarly to ARVC.1,2 This genetic test for ARVC 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 ARVC can be
accurately identified by genetic testing and managed appropriately. The value of genetic testing for ARVC
has been documented extensively in the medical literature, and 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 ARVC patients and their potentially at-risk family members.3-5
The FAMILION ARVC test is an accurate test for patients suspected to have ARVC, 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) Sen-Chowdhry S, Syrris P, McKenna WJ. Role of genetic analysis in the management of patients with
arrhythmogenic right ventricular dysplasia/cardiomyopathy. J Am Coll Cardiol. 2007;50:1813-1821. 2) Dalal D, Nasir K, Bomma C,
et al. Arrhythmogenic right ventricular dysplasia: a United States experience. Circulation. 2005;112:3823-3832. 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:e385-484. 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.