Insurance Company Name
Address
City, State
Date of claim
Re: Letter of Medical Necessity for Hereditary Nonpolyposis Colorectal Cancer
(HNPCC)/Lynch Syndrome Genetic 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 HNPCC/Lynch syndrome genetic testing (CPT Codes: 81292x1, 81295x1, 81298x1,
81294x1, 81297x1, 81300x1, 81403x1) to detect mutations in the MLH1, MSH2, EPCAM, MSH6
and PMS2 genes 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 Lynch syndrome predisposition is suspected in
individuals whose personal or family histories include any of the following:

Meeting the Amsterdam Criteria for HNPCC
o
Three of more family members, one being a first-degree relative with
HNPCC-related cancer

o
Two successive affected generations
o
One or more of the HNPCC-related cancers diagnosed at <50 years
o
Exclusion of FAP
Cancer diagnosed in multiple generations and/or multiple people within the same
generation

Colorectal cancer clustered with ovarian, uterine or other cancers
As such, First, Last Name personal and/or family history(ies) are suggestive of inherited
Lynch syndrome 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 surveillance for genespecific 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 genetic 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
complete and the laboratory will not bill until testing is concluded. Therefore, we are requesting
that the authorization be valid for 6 months.
SUMMARY OF DIAGNOSIS - ICD-9 CODES (check all that apply) – (use v codes for secondary dx)
 151.9 Malignant neoplasm of  183.0
the stomach, unsp.
 153.9 Malignant neoplasm of
the colon, unspecified
 179.9 Malignant neoplasm of
the uterus, unspecified
Malignant neoplasm of the
ovary and other uterine adnex
 211.3
Benign neoplasm of the colon
 V10.05 History malignancy large
intestine
 V12.72 History colon polyps
 V16.0
Family history of malignancy
GI tract
 V16.41 Family history malignancy ovary
 V18.9 Genetic disease carrier
 Others ______________________________
______________________________
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