A healthcare provider may include a Letter of Medical Necessity (LMN) with a pre-authorization request, claim submission, or appeal to facilitate the insurance review process for the benefit of the patient. Our experience with insurance companies is such that we encourage healthcare providers to cover as many of the following points as possible that are applicable to the patient:
- Explanation that the requested genetic test has been ordered by a physician
- Explanation of the medical necessity for the test requested
- If family history is cited, give as much family history as possible, including specifics about relationship to patient, cancer site, age of cancer diagnosis (alternatively, a detailed three-generation pedigree that contains this information could be attached and referred to in the body of the letter)
- Patient’s diagnosis and prognosis, including age of onset and specific location of cancer
- Explanation that the genetic test is recognized as appropriate for inclusion in this patient’s treatment regimen
- Treatment plan, including specific statements about anticipated impact of the genetic test on the medical management of patient.