LETTER OF MEDICAL NECESSITY FOR HEREDITARY GYNECOLOGIC CANCER GENETIC
TESTING
Date:
Date of service/claim
To:
Utilization Review Department
Insurance Company Name, Address, City, State
Re:
Patient Name, DOB, ID #
ICD-9 Codes: (list codes)
This letter is to urge you to provide coverage for medically-indicated hereditary gynecologic cancer
genetic testing for the above named patient.
The personal and/or family history reported on the test requisition form raises significant concern
for an inherited predisposition to ovarian and/or uterine cancer and indicates a reasonable
probability of detecting a causative gene mutation. There are many genes known to predispose to
ovarian and/or uterine cancer and the ordered genetic test analyzes 9 high-risk, well characterized
genes associated with hereditary gynecologic cancer: BRCA1, BRCA2, EPCAM, MLH1, MSH2, MSH6,
PMS2, PTEN, and TP53. These genes substantially increase the risk for ovarian and/or uterine
cancer and other cancers.
This multi-gene test is the most efficient and cost-effective way to analyze the implicated
gynecologic cancer genes and has significant potential to identify a causative gene mutation in the
patient. Identification of a causative gene mutation will clarify the patient’s future cancer risk(s)
and target medical management.
The rationale for testing is that the presence of a mutation in one of these genes places this patient
at a substantially increased risk for developing cancer and thus would influence our management
recommendations significantly. An aggressive approach to reduce the risk of cancer is indicated in
individuals who carry a gene mutation that predisposes them to cancer. If a mutation is identified,
we would recommend high-risk management to reduce the patient’s risk of developing an advanced
stage cancer and subsequently dying of the disease. As such, I am ordering this genetic test as
medically necessary care and affirm that the patient has provided informed consent for genetic
testing.
Please contact me if I can provide you with additional information.
Sincerely,
Ordering Clinician Name (Signature Provided on Test Requisition Form)
Test Details
CPT codes:
Laboratory:
81211x1, 81213x1, 81292x1, 81294x1, 81295x1, 81297x1, 81298x1, 81300x1, 81403x1
Ambry Genetics Corporation (TIN 33-0892453 / NPI 1861568784), a CAP-accredited and
CLIA-certified laboratory located at 15 Argonaut, Aliso Viejo, CA 92656