Download Insurance Company Name Address City, State Date of claim Re

Insurance Company Name
Address
City, State
Date of claim
Re: Ambry Genetics Corporation, Letter of Medical Necessity for Hereditary Cancer
Predisposition Testing
Patient First, Last Name
DOB
ID Number
Dear Medical Director,
This letter is in regards to my patient and your subscriber, First, Last Name to request full
coverage for cancer predisposition genetic testing to be performed by Ambry Genetics
Corporation (TIN 33-0892453 / NPI 1861568784), a CAP approved and CLIA certified laboratory
located at 15 Argonaut, Aliso Viejo, CA 92656.
The American Society of Clinical Oncology (ASCO) recommends that genetic testing be
offered to individuals with suspected inherited (genetic) cancer risk in situations where test
results can be interpreted, and when they can affect medical management of the patient (J Clin
Oncol. 2003 Jun 15; 21(12):2397-406). Inherited cancer predisposition is suspected in individuals
whose personal or family histories include any of the following:
 Cancer diagnosed at a young age
 Multiple primary tumors/bilateral tumors
 Rare tumor types
 Non-malignant findings known to be associated with cancer syndromes
 Cancer diagnosed in multiple generations and/or multiple people within the same
generation
As such, First, Last Name personal and/or family history(ies) are suggestive of inherited
cancer susceptibility. Based on my evaluation and review of the available literature, molecular
testing is crucial in order to establish/confirm a genetic syndrome diagnosis and in guiding
appropriate and immediate medical management. A positive genetic test result can provide the
following benefits to this patient:
 Appropriate surgical management and other treatment guidance
 Modification of cancer surveillance options and age of initial screening for gene-specific
associated cancers and
 Consideration of specific risk-reduction measures (e.g. prophylactic surgery and other
risk-reducing interventions) depending on the genetic alteration identified
Genetic testing will be performed through Ambry Genetics Corporation, given its longstanding experience with next-generation sequencing, consistent variant analysis, detailed
results reporting and continuous support from highly trained medical directors and genetic
counselors.
By ordering testing, I, the authorized clinician/medical professional acknowledge that the
patient has been supplied with information regarding genetic testing and the patient has given
informed consent for genetic testing to be performed and the signed consent form is on file. I
confirm that the ordered testing is medically necessary for the diagnosis or detection of a
predisposition to and/or current disease, illness, impairment, syndrome or disorder, and that
these results will be used in the medical management and treatment decisions for this patient.
I recommend that you support this request for coverage of diagnostic genetic testing for
hereditary cancer predisposition for my patient. Genetic testing can take up to four months to
SUMMARY OF DIAGNOSIS - ICD-9 CODES (check all that apply) – (use v codes for secondary dx)
151.90 Malignant neoplasm of
the stomach, unspecified
153.90 Malignant neoplasm of
the colon, unspecified
174.90 Malignant neoplasm of
the breast, unspecified
179.90 Malignant neoplasm of
183.00 Malignant neoplasm of the ovary
and other uterine adnex
211.30 Benign neoplasm of the colon
V12.72 History colon polyps
V16.00 Family history of malignancy
GI tract
233.30 Carcinoma in situ of breast
V16.30 Family history of malignancy breast
V10.05 History malignancy large
V16.41 Family history malignancy ovary
intestine
V10.30 History malignancy breast
the uterus, unspecified
V18.90 Genetic disease carrier
Others ______________________________
______________________________
complete and the laboratory will not bill until testing is concluded. Therefore, we are requesting
that the authorization be valid for 6 months.
Thank you for your time and please don’t hesitate to contact me with any questions.
Sincerely,
Ordering Clinician Signature ________________________________ Date ______________
(MD/DO, Clinical Nurse Specialist, Nurse-Midwives, Nurse Practitioner, Physician Assistant,
Genetic Counselor*)
*Authorized clinician requirements vary by state