[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.