Diagnosis: Family history of cancer.
Treatment: Genetic Testing for Lynch Syndrome.
The insurer denied the Genetic Testing for Lynch Syndrome.
The denial is overturned.

The patient is a male. Denial of genetic testing for Lynch syndrome is being appealed.

The request was previously denied by the health plan due to lack of medical records. Per clinical note, the patient's family history is as follows: Mother - breast cancer; maternal grandfather with possible colon; paternal grandfather with throat cancer; paternal grandmother with lung cancer. Order form for testing includes uncle with colon cancer. The patient had a colonoscopy with removal of 2 colonic polyps with unremarkable pathology.

Yes, the Genetic Testing for Lynch Syndrome is medically necessary.
Lynch syndrome is the most common form of genetically determined colon cancer predisposition. Revised Bethesda Guidelines for Lynch syndrome screening include the following:
1) Younger than 50 years when diagnosed with colorectal cancer;
2) Has or had a second colorectal cancer or another cancer linked to Lynch syndrome;
3) Younger than 60 years, and the cancer has certain characteristics seen with Lynch syndrome when it's viewed under a microscope;
4) Has a first-degree relative younger than 50 who was diagnosed with colorectal cancer or another cancer linked to Lynch syndrome (endometrial, stomach, pancreas, small intestine, bile duct, ovary, kidney or brain); or
5) Has 2 or more first- or second-degree relatives who had colorectal cancer or another Lynch syndrome-related cancer at any age.

This patient does not have a personal history of colorectal cancer. However, he has a family history of colorectal cancer in 2 second degree relatives in paternal grandfather and uncle. Therefore, given the above, the Genetic Testing for Lynch Syndrome is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.