Download medical necessity letter

LETTER OF MEDICAL NECESSITY FOR HEREDITARY BREAST CANCER 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 hereditary breast cancer
genetic testing for the above named patient.
The personal and/or family history reported on the test requisition form raises significant concern
for an inherited predisposition to breast cancer and indicates a reasonable probability of detecting
a causative gene mutation. There are many genes known to predispose to breast cancer and the
ordered genetic test analyzes 5 high-risk genes, with published medical management guidelines,
associated with hereditary breast cancer: BRCA1, BRCA2, CDH1, PTEN, and TP53. These genes
substantially increase the risk for breast and other cancers.
This multi-gene test is the most efficient and cost-effective way to analyze the implicated breast
cancer genes and has significant potential to identify a causative gene mutation in the patient.
Identification of a causative gene mutation will clarify the patient’s future cancer risk(s) and target
medical management.
The rationale for testing is the presence of a mutation in one of these breast cancer genes 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 gene mutation that predisposes them to cancer. 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.
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, 81321x1, 81323x1
Laboratory:
Ambry Genetics Corporation (TIN 33-0892453 / NPI 1861568784), a CAP-accredited and
CLIA-certified laboratory located at 15 Argonaut, Aliso Viejo, CA 92656