[Date] [Insurance Company] [Address 1] [Address 2] [City State Zip] Re: [Patient Name]

[Date]
[Insurance Company]

[Address 1]

[Address 2]

[City State Zip]

Re: [Patient Name]

Insurance ID: [ID #]

DOB: XX/XX/XXXX
To whom it may concern,
DNA diagnostic testing for Alport syndrome is recommended for the patient. Alport syndrome can be inherited in autosomal dominant, autosomal recessive and X-linked manners. Determining the specific causative gene and mutation allows for molecular testing of relatives to determine who is at risk to develop symptoms and would benefit from surveillance. Other benefits of molecular testing include: determination of recurrence risk for offspring and prenatal diagnosis. It may also allow the prediction of disease severity and enable individuals to know if they are eligible to be kidney donors for family members with Alport Syndrome who are in need of a renal transplant.
Biopsy and clinical history alone often cannot accurately diagnose the specific type of Alport syndrome in an affected individual. Thus, DNA diagnostic testing is often necessary. If individuals learn that they do not have the familial mutation causing Alport, they will not require the periodic monitoring of blood pressure, renal function, and hearing recommended for at risk individuals.
Please note that this test is performed for clinical management in a laboratory that is CLIA approved for high complexity testing.
Authorization should be obtained for:

Test name: [Test name]

Facility: ARUP Laboratories

CPT codes: [CPT codes]

Diagnosis code: [Diagnosis code]
Thank you for your time and attention to this matter.
Sincerely,

[Name of Ordering Physician]

References:

Kashtan, Clifford. GeneReviews. Alport syndrome and Thin Basement Neuropathy. http://www.ncbi.nlm.nih.gov/books/NBK1207/ accessed: 5.8.13.

From www.aruplab.com

Revision 1

Created: 01/25/2013