Genetic Testing for Hereditary Cancer | Ambry Genetics
LETTER OF MEDICAL NECESSITY FOR HEREDITARY CANCER GENETIC TESTING(CancerNext-Expanded)Date: Date of service/claim To:Utilization Review Department Insurance Company Name, Address, City, StateRe:Patient Name, DOB, ID #:ICD-10 Codes: (quick reference suggestions – Active diagnosis: C50.919 malignant neoplasm of unspecified site of unspecified female breast;?: C18.9 malignant neoplasm of colon, unspecified; C25.9 malignant neoplasm of pancreas, unspecified; C64.9 malignant neoplasm of unspecified kidney, except renal pelvis; C75.5 malignant of aortic body and other paraganglia; D35.6 benign neoplasm of aortic body and other paraganglia; Personal history: Z85.3 breast cancer; Z85.46 prostate cancer; Family history: Z80.3 breast cancer; Z83.71 colon cancer) This letter is in regards to my patient and your subscriber, First, Last Name to request full coverage of medically-indicated genetic testing for hereditary cancer to be performed by Ambry Genetics Corporation.Cancer is thought to have a hereditary component in up to 10% of cases; evaluating personal and family histories is a major part of hereditary cancer risk assessment. Mutations in multiple genes cause hereditary cancer, which markedly increase the lifetime risk for many types of cancer. Some of these gene mutations also increase the lifetime risk for other cancers (such as ovarian, uterine, colorectal, sarcomas, brain, leukemia, gastric, thyroid, and prostate). Significant aspects of my patient’s personal and/or family medical history that suggest a reasonable probability of hereditary cancer are below:A history clearly suggestive of hereditary cancerSeveral cancers in the family that do not seem to fit a particular hereditary cancer syndrome (demonstrating a need for a multi-gene approach to testing)A family history with features of several hereditary cancer syndromesCancer diagnosed at a younger age than expected for the general population (≤ 50 years, for most cancers)Multiple people with cancer on the same side of the family across generations, and in multiple generationsAn individual with multiple primary cancers A family history of cancer that is typical of a known cancer predisposition syndrome Based on this, I am requesting coverage for this test (CancerNext-Expanded). CancerNext-Expanded includes comprehensive analysis of 77 genes associated with hereditary cancer: AIP, ALK,?APC, ATM, AXIN2, BAP1, BARD1, BLM, BMPR1A, BRCA1, BRCA2, BRIP1, CDC73, CDH1, CDK4, CDKN1B, CDKN2A, CHEK2, CTNNA1, DICER1, EGFR, EGLN1, EPCAM, FANCC, FH, FLCN, GALNT12, GREM1, HOXB13, KIF1B, KIT, LTZR1, MAX, MEN1, MET, MITF, MLH1, MSH2, MSH3, MSH6, MUTYH, NBN, NF1, NF2, NTHL1, PALB2, PDGFRA, PHOX2B, PMS2, POLD1, POLE, POT1, PRKAR1A, PTCH1, PTEN, RAD51C, RAD51D, RB1, RECQL, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, SMAD4, SMARCA4, SMARCB1, SMARCE1, STK11, SUFU, TMEM127, TP53, TSC1, TSC2, VHL, XRCC2.Based on the above personal and/or family history, my patient is suspicious for ______________________ syndrome(s). As clinical features of many hereditary cancer syndromes overlap and there is a reasonable probability of detecting a mutation in my patient, this multi-gene test is the most efficient, cost-effective way to analyze the multiple genes associated with hereditary cancer conditions.3 According to published guidelines, germline genetic testing is warranted.1,2 This genetic testing will help estimate my patient’s risk to develop cancer/another primary cancer and directly impact my patient’s medical management. Many of the genes in this test have published clinical practice guidelines to reduce the risk for cancer and/or detect cancer early, to reduce morbidity and mortality. Management options may include:Increased breast screening including self-examinations, clinical breast examinations, mammogram, ultrasound, and MRIBreast cancer risk reduction using prophylactic mastectomies and/or chemopreventionRisk-reducing bilateral salpingo-oophorectomy and/or hysterectomy Prostate cancer screening (PSA and DRE)Annual thyroid ultrasound and examMore frequent colonoscopyAvoidance of radiation treatment when possible Consideration of MRI-based screening/technologiesOther: _____________________________________________________Due to the cancer risks associated with these mutations and interventions available to reduce these risks, this genetic testing is medically indicated. As such, I am ordering this testing as medically necessary and affirm that my patient has provided informed consent for genetic testing.A positive test result would confirm a genetic diagnosis and/or risk in my patient and would ensure my patient is being managed appropriately. I am specifying Ambry Genetics Corporation because this laboratory has highly-sensitive4 and cost-effective testing for hereditary cancer, along with a large database of previously tested patients to ensure highly validated, accurate, and informative test interpretation. I recommend that you support this request for coverage of diagnostic genetic testing for hereditary cancer in my patient.Thank you for your time, and please don’t hesitate to contact me with any questions. Sincerely,Ordering Clinician Name (Signature Provided on Test Requisition Form) (MD/DO, Clinical Nurse Specialist, Nurse-Midwives, Nurse Practitioner, Physician Assistant, Genetic Counselor*) *Authorized clinician requirements vary by state Test DetailsCPT codes:81162, and 81201, 81292, 81294, 81295, 81297, 81298, 81300, 81317, 81319, 81321, 81403, or 81432, 81433, or 81435, 81436, or 81479Laboratory: Ambry Genetics Corporation (TIN 33-0892453 / NPI 1861568784), a CAP-accredited and CLIA-certified laboratory located at 7 Argonaut, Aliso Viejo, CA 92656References:NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines?). Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic. Version 1.2020, 12/04/2019. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines?). Genetic/Familial High-Risk Assessment: Colorectal. Version 3.2019, 12/13/2019. Meldrum C, Doyle MA, Tothill RW. Next-generation sequencing for cancer diagnostics: a practical perspective. Clin Biochem Rev. 2011 Nov;32(4):177-95.Mu W, et al. Sanger confirmation is required to achieve optimal sensitivity and specificity in next-generation sequencing panel testing. J Mol Design. 2016 Nov;18(6):923-932. ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- medical necessity letter ambry gen
- c p service clinician s guide veterans affairs
- questions for pc practicum unit 6 coding quiz
- table of contents
- department of veterans affairs home veterans
- hedis stars measures reference guide for 2020 2021
- genetic testing for hereditary cancer ambry genetics
- patient care encounter pce user manual
- 2021 uds manual tables uds bphc
- instructor s guide for icd 9 cm diagnostic coding and
Related searches
- genetic testing for hypertrophic cardiomyopathy
- genetic testing for autoimmune diseases
- genetic testing for collagen disorders
- genetic testing for prostate cancer
- genetic testing cpt code
- genetic testing cpt codes 2019
- genetic testing cpt code 81479
- genetic testing cpt code range
- bladder cancer testing for men
- genetic testing for lupus
- aim genetic testing guidelines
- genetic testing for cardiomyopathy