[Date]
[Insurance Company]
[Address 1]
[Address 2]
[City State Zip]
Re: [Patient Name]
Insurance ID: [ID #]
DOB: XX/XX/XXXX
To whom it may concern,
I have given serious consideration towards this patient’s underlying diagnosis and while I think that it is highly
likely that [he/she] has a genetic syndrome, at the present time I cannot recognize a specific entity. The overall
clinical picture of an individual with [symptomatology, such as developmental disabilities and dysmorphic
features] raises concern for a multi-gene disorder such as would be found in a structural chromosome aberration
(e.g., a chromosome deletion or duplication).
Currently, the most comprehensive and cost-effective method for detecting deletions and duplications of genetic
material is via the whole genome chromosomal microarray analysis. Supporting this, the American Society of
Human Genetics recently published a policy statement recommending that microarray analysis be performed as a
first-tier diagnostic test for individuals, such as my patient, with developmental disabilities or congenital
anomalies1. In addition, the results of chromosomal microarray analysis have been shown to significantly impact
medical management2.
I feel that the microarray test is necessary for my patient to determine the nature of [his/her] condition and
appropriate medical management and therapies in a timely fashion. In the absence of this testing, I will not be able
to provide a diagnosis or appropriate management recommendations for this patient’s care.
Please note that this test is performed for clinical management in a laboratory that is CLIA approved for high
complexity testing.
Please take these factors into consideration and provide the coverage for the microarray test that I am
recommending for this patient.
Authorization should be obtained for:
Test name: Cytogenomic SNP Microarray
Facility: ARUP Laboratories
CPT codes: [CPT codes]
Diagnosis code: [Diagnosis code]
Thank you for your time and attention to this matter.
Sincerely,
From www.aruplab.com
Revision 1
Created: 09/30/2011
[Name of Ordering Physician]
References:
1. Miller DT, et al. Consensus statement: chromosomal microarray is a first-tier clinical diagnostic test for individuals with developmental
disabilities or congenital anomalies. Am J Hum Genet 2010;86(5): 749-764.
2. Coulter BA, et al. Chromosomal microarray testing influences medical management. Genet Med 2011;13(9): 770-776.
From www.aruplab.com
Revision 1
Created: 09/30/2011