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Transcript
LETTER OF MEDICAL NECESSITY FOR BRCA1/BRCA2 GENETIC TESTING Date: Date of service/claim To: Utilization Review Department Insurance Company Name, Address, City, State Re: Patient Name, DOB, ID # ICD-9 Codes: (list codes) This letter is to urge you to provide coverage for medically-indicated BRCA1/BRCA2 genetic testing for the above named patient. The personal and/or family history reported on the test requisition form raises significant concern for hereditary breast and ovarian cancer syndrome and indicates a reasonable probability of detecting a BRCA1/BRCA2 mutation in the patient. Women who carry a BRCA1 or BRCA2 mutation have up to an 85% chance of developing breast cancer (compared to 12% in the general population), a 40-60% risk for a second primary (ipsilateral or contralateral) breast cancer, and a 15-45% chance of developing ovarian cancer (compared to 1.6% in the general population.) Men who carry a BRCA1 or BRCA2 mutation have an elevated risk for breast and prostate cancer. The rationale for testing is the presence of a BRCA mutation places this patient at a substantially increased risk for developing cancer and thus would influence our care recommendations significantly. An aggressive approach to reduce the risk of cancer is indicated in individuals who carry a BRCA1 or BRCA2 mutation. If a mutation is identified, we would recommend high-risk management to reduce the patient’s risk of developing an advanced stage cancer and subsequently dying of the disease. As such, I am ordering this genetic test as medically necessary care and affirm that the patient has provided informed consent for genetic testing. Full-gene sequencing and deletion/duplication analysis of BRCA1 and BRCA2 is warranted, consistent with guidelines established by the American Society of Clinical Oncologists (ASCO) and the National Comprehensive Cancer Network (NCCN). These services are recognized as standard of care in the community (as evidenced by coverage by most major indemnity plans). Please contact me if I can provide you with additional information. Sincerely, Ordering Clinician Name (Signature Provided on Test Requisition Form) Test Details CPT codes: 81211x1, 81213x1 Laboratory: Ambry Genetics Corporation (TIN 33-0892453 / NPI 1861568784), a CAP-accredited and CLIA-certified laboratory located at 15 Argonaut, Aliso Viejo, CA 92656