[INSERT_DATE]
RE:
Genetic Testing for Long QT Syndrome Deletion/Duplication 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 long QT syndrome
(LQTS): CPT codes [INSERT CPT CODES] with diagnosis code(s) of [INSERT_ICD10_CODES].
I suspect my patient has the inheritable arrhythmia disorder known as long QT syndrome, based on the
following medical history, signs and symptoms: [INSERT DETAILS, e.g., prolonged QTc interval, history
of Torsades de Pointes, T-wave alternans, >3 leads with notched T-waves, low heart rate for age, syncope,
aborted sudden cardiac arrest, congenital deafness, family member(s) with long QT syndrome,
unexplained sudden cardiac death in family members].
The long QT syndrome is a potentially lethal disorder made up of several different subtypes that can only be
determined by a genetic test. Determination of the specific subtype involved is important because each is
associated with a different risk for sudden cardiac death, different event triggers, and different
pharmacological therapies and interventional strategies.1 Results from this test will enable a
comprehensive risk assessment to be conducted for sudden cardiac death and guide treatment
decisions, including whether my patient can be managed pharmacologically or may require an
implanted cardiac defibrillator. The test results are also important for this patient’s family members: if a
mutation is identified, then relatives at risk for long QT syndrome can be accurately identified by genetic
testing and managed appropriately. The value of genetic testing for long QT syndrome has been documented
extensively in the medical literature, and 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 long QT syndrome patients
and their potentially at-risk family members.2-4
The FAMILION long QT syndrome test is an accurate test for patients suspected to have long 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) Crotti L, Celano G, Dagradi F, et al. Congenital long QT syndrome. Orphanet J Rare Dis. 2008;3:18. 2) 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. 3) 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;8:130839. 4) 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;10:1932-63.