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Patient/Member Information

Patient Name: DOB:

Subscriber Name:DOBSubscriber Number:

Provider/Contact Information

Ordering Provider:

Contact Person:Phone:Fax:

Genetic Test Information

Name of test:Microarray Comparative Genomic Hybridization (CGH)

Test Code:

CPT code(s):

ICD10 code(s):

List price:

Do you have a preferred clinical laboratory for genetic testing?

X NO (or not applicable)

__ YES, (provide preferred lab name):

Please state the reason why testing should/must be performed at this laboratory:

Clinical Reasoning for Genetic Test (Attach the clinic note)

*** is a *** year old *** 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?Microarray CGH has the ability to test for a broad range of microscopic and submicroscopic chromosomal abnormalities. Microarray CGH has a diagnostic yield of 15%-20% for testing of individuals with unexplained developmental disability/intellectual disability, autism spectrum disorders or multiple congenital anomalies1. Given this diagnostic yield, the microarray CGH is part of the standard of care for children with unexplained developmental delay, autism spectrum disorders and/or multiple congenital anomalies.3,4 In addition, microarray CGH results have been shown to impact medical management2.

-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: A clinically significant result consistent with the patient’s phenotype would stop the need for further genetic testing.

Inform on prognosis:A clinically significant result will allow us to analyze precedent and provide information to the family on other individuals with the chromosomal change regarding natural history and prognosis (if available).

Change treatment plan (e.g. medical or surgical decision-making or treatment):

Change surveillance (e.g. annual echocardiograms, either begin or stop):See Ref. 2

Provide information for family members:Identification of a clinically significant finding on microarray CGH would allow for @FNAME@ to better understand the risk to @HIS@ future children and offer targeted testing to at-risk family members. A positive result would also allow for expanded reproductive options including preimplantation genetic diagnosis.

-What is the probability that this test will be positive? If this is not known, then please indicate which clinical features increase the probability that this test will provide a diagnosis. Microarray CGH has a detection rate of 15%-20% among individuals with developmental disabilities, autism or multiple congenital anomalies.

-If this is a request is for a gene panel, describe why a single gene test is not as useful.NA

-Please list specific guidelines and/or references in support of your request:

1.Miller DT et al. Consensus statement: chromosomal microarray is a first-tier clinical diagnostic test for individuals with developmental disabilities or congenital anomalies. Am J Hum Genet 2013;86:749-764.

2.Coulter BA, et al. Chromosomal microarray testing influences medical management. Genet Med 2011;13(9): 770-776.

3.Manning M et al. Array-based technology and recommendations for utilization in medical genetics practice for detection of chromosomal abnormalities. Genet Med 2010;12(11): 742-745.

4.American Academy of Pediatrics. Genetic and Metabolic Testing on Children With Global Developmental Delay. Pediatrics 2012;129:e825.