Insurance Company Name
Address
City, State
Date of claim
Re: Letter of Medical Necessity for Hereditary Renal (Kidney) Cancer Genetic Testing
Patient First, Last Name
DOB
ID Number
Dear Medical Director,
This letter is in regards to my patient and your subscriber, First, Last Name to request full
coverage for hereditary renal cancer genetic testing (CPT codes: 81292x1, 81294x1, 81295x1, 81297x1,
81298x1, 81300x1, 81317x1, 81319x1, 81321x1, 81323x1) to be performed by Ambry Genetics
Corporation (TIN 33-0892453 / NPI 1861568784), a CAP approved and CLIA certified laboratory
located at 15 Argonaut, Aliso Viejo, CA 92656.
The American Society of Clinical Oncology (ASCO) recommends that genetic testing be offered
to individuals with suspected inherited (genetic) cancer risk in situations where test results can be
interpreted, and when they can affect medical management of the patient (J Clin Oncol. 2003 Jun 15;
21(12):2397-406). Inherited renal cancer predisposition is suspected in individuals whose personal
or family histories include any of the following:
 Renal cancer diagnosed at a young age (<45 years-of-age)
 Multiple primary cancers in one person (eg. two primary renal cancers, renal, thyroid or
colon cancer)
 Two or more family members with renal cancer (on the same side of the family)
 Three or more family members with renal, thyroid, colon, ovarian or other cancers on the
same side of the family
 Multiple close family members with renal cancer and neuroendocrine tumors (on the same
side of the family)
As such, First, Last Name personal and/or family history(ies) are suggestive of inherited renal
cancer susceptibility. Based on my evaluation and review of the available literature, molecular
testing is crucial in order to establish/confirm a genetic syndrome diagnosis and in guiding
appropriate and immediate medical management. A positive genetic test result can provide the
following benefits to this patient:
 Appropriate surgical management and other treatment guidance
 Modification of cancer surveillance options and age of initial surveillance for gene-specific
associated cancers and
 Consideration of specific risk-reduction measures (e.g. prophylactic surgery and other riskreducing interventions) depending on the genetic alteration identified
Genetic testing will be performed through Ambry Genetics Corporation, given its long-standing
experience with next-generation sequencing, consistent variant analysis, detailed results reporting
and continuous support from highly trained medical directors and genetic counselors.
The genetic test detects mutations in 18 genes associated with hereditary renal cancer
susceptibility with varying lifetime risks. Tested genes include: EPCAM, FH, FLCN, MET, MITF,
MLH1, MSH2, MSH6, PMS2, PTEN, SDHA, SDHB, SDHC, SDHD, TP53, TSC1, TSC2, VHL. NGS
technology can simultaneously analyze these 18 genes, providing results in a shorter time period
and at a fraction of the cost of traditional approaches like Sanger sequencing.
By ordering genetic testing, I, the authorized clinician/medical professional acknowledge that
the patient has been supplied with information regarding genetic testing and the patient has given
informed consent for genetic testing to be performed and the signed consent form is on file. I
confirm that the ordered testing is medically necessary for the diagnosis or detection of a
predisposition to and/or current disease, illness, impairment, syndrome or disorder, and that these
results will be used in the medical management and treatment decisions for this patient.
I recommend that you support this request for coverage of diagnostic genetic testing for hereditary
cancer predisposition for my patient. Genetic testing can take up to four months to complete and
the laboratory will not bill until testing is concluded. Therefore, we are requesting that the
authorization be valid for 6 months.
SUMMARY OF DIAGNOSIS - ICD-9 CODES (CHECK ALL THAT APPLY) – (USE V CODES FOR SECONDARY DX)
153.9
Malignant neoplasm of
183.0
the colon, unspecified
157.9
Malignant neoplasm of the ovary
V12.72 History colon polyps
and other uterine adnex
V16.0
Family history of malignancy GI tract
Family history of malignancy breast
Malignant neoplasm of
189.0
Malignant neoplasm of kidney
V16.3
pancreas, unspecified
189.1
Malignant neoplasm of renal pelvis
V16.51 Family history of malignancy kidney
174.9
Malignant neoplasm of
189.2
Malignant neoplasm of ureter
V16.52 Family history of malignancy bladder
the breast, unspecified
189.9
Malignant neoplasm of urinary
V18.9 Genetic disease carrier
179.9
Malignant neoplasm of
organ, unspecified
Others ______________________________
the uterus, unspecified
V10.3 History malignancy breast
______________________________
Thank you for your time and please don’t hesitate to contact me with any questions.
Sincerely,
Ordering Clinician Signature ________________________________ Date ______________
(MD/DO, Clinical Nurse Specialist, Nurse-Midwives, Nurse Practitioner, Physician Assistant, Genetic Counselor*)
*Authorized clinician requirements vary by state