Limb Girdle Muscular Dystrophy Advanced Evaluation
<Date>
ATTN:
<Medical Director/ Physician Name>, MD
<Institution/Insurance Company>
<Street Address>
<City>, <State> <Zip>
RE:
DOB:
Member ID:
Group #:
<Patient Name>
<MM/DD/YYYY>
<Insurance ID Number>
<Enter Group #>
Dear Medical Director:
I am writing on behalf of my patient <Patient Name> to request coverage for the Athena Diagnostics Limb Girdle
Muscular Dystrophy Advanced Evaluation (23 genes). I have determined that this test is medically necessary
because of the following aspects of my patient’s history:
<Patient Name> is a <age> -year-old <gender > with a suspected diagnosis of muscular dystrophy due to the
following symptoms and clinical findings:
1. <Symptom #1 with ICD-9 code>
2. <Symptom #2 with ICD-9 code>
3. <Symptom #3 with ICD-9 code>
< Add additional details if relevant >
The patient’s family history of limb girdle muscular dystrophy (LGMD) is <negative or unknown; add additional details
if relevant>.
Additionally, the following testing has previously been performed: <testing previously performed, and how it rules out
other etiology>.
Rationale for Testing
LGMD is a heterogeneous group of disorders characterized by voluntary muscular weakness and wasting of mainly
proximal muscles, specifically around the shoulders and pelvis. The over 24 identified subtypes of LGMD can vary
widely in severity and prognosis.1 Definitive diagnosis is crucial because management of the disease, particularly with
respect to cardiac and respiratory involvement, is based on the subtype.1 However, the specific subtype of LGMD can
be difficult to determine because of variability in the age of disease onset and progression of symptoms.
Traditional DNA sequencing using Sanger-based methodology to detect individual mutations can be time consuming
and costly when testing a large numbers of genes. Next-generation sequencing (NGS), on the other hand, allows
sequencing of multiple genes simultaneously. Thus, targeted NGS panels seem appropriate for detecting mutations
in disorders that have highly heterogeneous genetic backgrounds, such as the LGMDs.
Results from the test may be used to confirm the diagnosis of LGMD in this patient and to guide medical
management and treatment. Specifically, the results may:

Inform treatment decisions; for example:

Selection of appropriate treatment options, including cardiac and respiratory interventions to prevent
life-threatening complications.1

Help identify candidates for clinical trials for genetically defined muscular dystrophies.

Help avoid a long series of laborious and potentially costly diagnostic procedures.

Provide information useful for family planning.
In summary, I am requesting that <Patient Name> be approved for the Limb Girdle Muscular Dystrophy Advanced
Evaluation (test code 5519) offered by Athena Diagnostics. The CPT codes for this test are 81404(3), 81405(7),
81406(6), 81408(1), 81479(1). I hope you will support my decision to perform LGMD genetic testing for this patient.
Please feel free to contact me at <Physician Phone> if you have additional questions.
Sincerely,
<Physician Name>, MD
NPI #: <Physician NPI#>
Contact information:
< Address>
<City>, <State> <Zip>
Contact Phone No.: <phone number>
References
1. Pegoraro E and Hoffman EP. Limb-Girdle Muscular Dystrophy Overview (last updated 2012). In: Pagon RA,
Adam MP, Bird TD, Dolan CR, Fong CR, Stephens K, eds. GeneReviews. Seattle (WA); 1993.