[INSERT_DATE]
RE:
Genetic Testing for Long 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 long QT syndrome
(LQTS): S-Code S3860 or CPT4 codes 83891 (1 unit), 83898 (108 units), 83904 (108 units), 83909 (108
units) and 83912 (1 unit) with diagnosis code(s) of [INSERT_ICD9_CODES].
I suspect my patient has the inheritable arrhythmia disorder known as long QT syndrome, based on the
following medical history, signs and symptoms:
Electrocardiographic Findings
Clinical History
[ ] Prolonged QTc interval:
[ ] Syncope: [ ] With stress [ ] Without stress
____________ms
[ ] Aborted sudden cardiac arrest
[ ] History of Torsades de Pointes
[ ] Congenital deafness
[ ] T-wave alternans
Family History
[ ] >3 leads with notched T-waves
[ ] Family member(s) with long QT syndrome
[ ] Low heart rate for age
[ ] 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 the American College of Cardiology, American Heart Association
and the European Society of Cardiology have issued evidence-based practice guidelines recommending
genetic testing for all long QT syndrome patients and their potentially at-risk family members.2
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.