Download [INSERT_DATE] RE: Genetic Testing for Left Ventricular

[INSERT_DATE]
RE:
Genetic Testing for Left Ventricular Noncompaction 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 Left Ventricular
Noncompaction Cardiomyopathy (LVNC): CPT codes [INSERT CPT CODES] with diagnosis code(s) of
[INSERT_ICD10_CODES].
I suspect my patient has the life-threatening, inheritable heart disorder LVNC, based on the following
medical history, signs and symptoms: [INSERT DETAILS, e.g., dilation of the left ventricle, left ventricular
hypertrophy, systolic and/or diastolic dysfunction, atrial and/or ventricular arrhythmias, noncompaction of
the myocardium, syncope, aborted sudden cardiac arrest, family member(s) with LVNC, unexplained sudden
cardiac death in relatives].
LVNC is a genetic cardiomyopathy that may clinically manifest as heart failure, arrhythmias, and/or
thromboembolic events.1,2 LVNC poses several challenges in both diagnosis and management and, if left
untreated, can result in death, including sudden cardiac death.2 Reliance solely on imaging modalities, such
as echocardiogram and cardiac MRI, provides low diagnostic specificity for LVNC and can frequently lead
to a misdiagnosis of LVNC.3 This genetic test for LVNC 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 LVNC can be accurately identified by genetic
testing and managed appropriately. The value of genetic testing for LVNC has been documented extensively
in the medical literature, and the Heart Failure Society of America, Heart Rhythm Society, and European
Heart Rhythm Association have issued practice guidelines recommending genetic testing for all LVNC
patients and their potentially at-risk family members.4,5
The FAMILION LVNC test is an accurate test for patients suspected to have LVNC, 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) Maron BJ, Towbin JA, Thiene G, et al. Contemporary Definitions and Classification of the Cardiomyopathies.
Circulation. 2006;113:1807-1816. 2) McNally E, Dellefave L. Sarcomere mutations in cardiogenesis and ventricular noncompaction.
Trends Cardiovasc Med. 2009;19:17-21. 3) Sen-Chowdhry S, McKenna WJ. Left ventricular noncompaction and cardiomyopathy:
cause, contributor, or epiphenomenon? Curr Opin Cardiol. 2008;23:171-5. 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.