[INSERT_DATE]
RE:
Genetic Testing for Short QT Syndrome Letter of Medical Necessity
Patient Name: [PATIENT_FULL_NAME]
DOB: [DATE_OF_BIRTH]
Subscriber/ID Number: [POLICY_NUMBER]
To Whom It May Concern:
I am writing on behalf of my patient to request authorization for genetic testing for short QT syndrome: CPT
codes [INSERT CPT CODES] with diagnosis code(s) of [INSERT_ICD10_CODES].
I suspect my patient has the inheritable arrhythmia disorder known as short QT syndrome, based on the
following medical history, signs and symptoms: INSERT DETAILS, e.g.,shortened QTc interval, tall Twaves, atrial fibrillation, syncope, aborted sudden cardiac arrest, family member(s) with short QT
syndrome, unexplained sudden cardiac death in family members].
Short QT syndrome is an inherited and potentially lethal disorder.1 Sudden death is the clinical presentation
for approximately one-third of individuals affected by SQTS.2 Clinical investigations of short QT syndrome
are often non-specific and may not identify the underlying cause. Genetic testing is an important criterion for
making a diagnosis of short QT syndrome.3 This genetic test for is a critical component of a
comprehensive diagnostic workup and the results will guide treatment decision-making, including
whether my patient may require an implantable cardioverter defibrillator. The test results are also
important for this patient’s family members: if a mutation is identified, then relatives at risk for short QT
syndrome can be accurately identified by genetic testing and managed appropriately. The value of genetic
testing for short QT syndrome has been documented in the medical literature, and the American College of
Cardiology, American Heart Association, European Society of Cardiology, Heart Rhythm Society, and
European Heart Rhythm Association have issued evidence-based practice guidelines recommending genetic
testing for all short QT syndrome patients and their potentially at-risk family members.4-6
The FAMILION short QT syndrome test is an accurate test for patients suspected to have short QT syndrome,
and is performed in a CLIA-certified laboratory that meets all applicable state and federal guidelines. The
results of this test are medically necessary to guide treatment of this patient. Thank you for your time
and consideration of my request. Please contact me if you wish to discuss my patient’s treatment plan or
require additional information.
Respectfully,
[INSERT_PHYSCIAN_NAME,
ADDRESS,
AND_PHONE_NUMBER]
References: 1) Schimpf R, et al. Clinical and molecular genetics of the short QT syndrome. Curr Opin Cardiol. 2008;23:192-8. 2)
Giustetto C, Schimpf R, Mazzanti A, et al. Long-Term Follow-Up of Patients With Short QT Syndrome. J Am Coll Cardiol.
2011;58:587-95. 3) Gollob MH, Redpath CJ, Roberts JD. The Short QT Syndrome Proposed Diagnostic Criteria. J Am Coll Cardiol.
2011;57:802-12. 4) Zipes DP, Camm AJ, Borggrefe M, et al. ACC/AHA/ESC 2006 Guidelines for Management of Patients With
Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2006;114:e385-484. 5) Ackerman MJ, Priori SG,
Willems S, et al. HRS/EHRA expert consensus statement on the state of genetic testing for the channelopathies and
cardiomyopathies. Heart Rhythm. 2011;8:1308-39. 6) Priori SG, Wilde AA, Horie M, et al. HRS/EHRA/APHRS expert consensus
statement on the diagnosis and management of patients with inherited primary arrhythmia syndromes. Heart Rhythm. 2013;10:193263.