Medical Necessity Justification
Patient/Member InformationPatient Name: DOB:Payor: Plan: Subscriber Name:DOBSubscriber Number:Provider/Contact InformationOrdering Provider:Contact Person:Phone:Fax:Genetic Test InformationName of test: Epilepsy Panel (89 genes)Test Code: 03402CPT code(s): 81479ICD10 code(s):List price:Do you have a preferred clinical laboratory for genetic testing? __ NO (or not applicable) X YES, (provide preferred lab name): InvitaePlease state the reason why testing should/must be performed at this laboratory: Clinical Reasoning for Genetic Test (Attach the clinic note)*** is a *** yo with a history of ***. -What laboratory and/or clinical testing have been performed to date (genetic and other testing)?-Why is genetic testing necessary at this time? Epilepsy is a group of disorders caused by disturbances with electrical signaling in the brain. Epilepsy may present as an isolated finding or as part of a broader phenotype. Several syndromic neurodevelopmental disorders include epilepsy as a prominent feature. Furthermore, several phenotypic subgroups of epilepsy exist. PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk90dG1hbjwvQXV0aG9yPjxZZWFyPjIwMTA8L1llYXI+PFJl
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ADDIN EN.CITE.DATA 1 These types include early-onset spasms, X-linked infantile spasms, Dravet and related syndromes, Ohtahara syndrome, epilepsy and mental retardation limited to females (now known as PCDH19 female-limited epilepsy), early-onset absence epilepsy, autosomal dominant nocturnal frontal lobe epilepsy, and epilepsy with paroxysmal exercise-induced dyskinesia. Distinction between the phenotypic subgroups provides helpful information for prognostic and genetic counseling and clinical care. Epilepsy is a highly heterogeneous genetic disorder, meaning many genes have been associated with epilepsy. For example, mutations in genes encoding ion channels, proteins associated to the vesical synaptic cycle or proteins involved in energy metabolism are known to cause epilepsy. The large number of genes associated with epilepsy complicates the genetic diagnosis.-How will the results of the genetic test, whether negative or positive, impact the future management of the member being tested? (explain all that apply):Stop the need for further diagnostic testing: As the NGS assay covers multiple relevant genes using a single blood draw, it can potentially help avoid a long series of laborious, costly, and stressful diagnostic procedures. Inform on prognosis:Change treatment plan (e.g. medical or surgical decision-making or treatment): Depending on the specific mutations identified, test results could help guide antiepileptic pharmacotherapy in some cases. For example, administration of sodium channel blockers would be avoided in patients with Dravet syndrome harboring an SCN1A mutation, while detection of an ALDH7A1 mutation might suggest responsiveness to pyridoxine (depending on other clinical features).PFJlZm1hbj48Q2l0ZT48QXV0aG9yPk1pbGxzPC9BdXRob3I+PFllYXI+MjAxMDwvWWVhcj48UmVj
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ADDIN EN.CITE.DATA 4-If this is a request is for a gene panel, then please describe why a single gene test is not as useful. The clinical sensitivity of this test is dependent on the patient’s underlying genetic condition. For each condition, the table below shows the percentage of clinical cases in which a pathogenic variant is expected to be identified through analysis of the genes on this panel.Sensitivity by clinical conditionGenes71% of epileptic encephalopathy CHD2, CDKL5, KCNQ2, PCDH19, SCN1A, SCN2A, SYNGAP190% of benign familial epilepsy (KCNQ2, KCNQ3, PRRT2, SCN2A75% of Dravet syndrome PCDH19, SCN1A35% of Ohtahara syndrome STXBP120%–25% of autosomal dominant nocturnal frontal lobe epilepsy CHRNA2, CHRNA4, CHRNB2, DEPDC5, KCNT110% of early onset absence epilepsy and 90% of GLUT1 deficiency encephalopathy SLC2A1Unknown for rare subtypes of EIEEADSL, ALDH7A1, ALG13, ARHGEF9, ARX, ATP1A2, CACNA2D2, CLN3, CLN5, CLN6, CLN8, CSTB, CTSD, DNAJC5, EFHC1, EPM2A, FOLR1, GABRA1, GABRB3, GABRG2, GAMT, GATM, GNAO1, GOSR2, GRIN1, GRIN2A, GRIN2B, HCN1, HNRNPU, KCNH2, KCNJ10, KCTD7, LGI1, LIAS, MFSD8, NHLRC1, PLCB1, PNKP, PNPO, POLG, PPT1, PRICKLE1, QARS, RBFOX1, ROGDI, SCARB2, SCN1B, SCN3A, SCN5A, SCN9A, SLC25A22, SLC35A2, SLC6A8, SPTAN1, SYN1, TBC1D24, TPP1, TSC1, TSC2, WWOXRett/Atypical Rett syndromesMECP2: 95% of females with Rett syndrome cases and 75% of females with atypical Rett syndrome cases; CDKL5: 13% of atypical Rett syndrome cases; FOXG1: 1% of Rett syndrome cases; MBD5 and MEF2C are rare causes of Rett-like syndrome.Angelman/Angelman-like syndromes*UBE3A: 90% of Angelman syndrome cases; SLC9A6: 6% of Angelman syndrome cases; MBD5: Rare cause of Angelman-like syndrome (Christianson syndrome) cases); MECP2: Rare cause of Angelman-like syndrome cases.Pitt-Hopkins syndromeTCF4: 38% of Pitt-Hopkins syndrome cases.Mowat-Wilson syndrome**ZEB2: 98% of Mowat-Wilson syndrome cases.Koolen-DeVries syndrome (17q21.31 microdeletion syndrome)KANSL1: 100% of Koolen-DeVries syndrome cases.adenylosuccinate lyase deficiencyADSL: 100% of adenylosuccinate lyase deficiency cases alpha-thalassemia X-linked intellectual disability (ATRX) syndromeATRX: 100% of ATRX syndrome cases.Glass syndromeSATB2: 100% of Glass ?syndromesuccinic semialdehyde dehydrogenase (SSADH) deficiencyALDH5A1: 100% of SSADH deficiency cases. ................
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