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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:Hypoglycemia Gene Panel

Test Code:

CPT code(s):

ICD10 code(s):

List price:

Do you have a preferred clinical laboratory for genetic testing?

__ NO (or not applicable)

_ YES, (provide preferred lab name):Baylor College Genetics Laboratory

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

Clinical Reasoning for Genetic Test (Attach the clinic note)

@FNAME@ is a @AGE@ @SEX@ 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?Hypoglycemia, or recurrent episodes of very low blood glucose levels, can occur at any time during the lifespan1. If untreated, hypoglycemia can cause brain injury and downstream effects such as neurocognitive defects, aphasia and hemiparesis2. Accurate recognition and urgent treatment of hypoglycemic episodes are, therefore, crucial1. Due to the fact that there is a wide differential diagnosis for childhood hypoglycemia, molecular genetic testing is integral in the diagnostic process.

-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: Additional genetic testing would not be pursued if the gene panel identified a clinically significant result consistent with the patient’s phenotype.

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

Change treatment plan (e.g. medical or surgical decision-making or treatment):A clinically significant result has the potential to lead to a specific treatment or management strategy that changes clinical outcome.

Change surveillance (e.g. annual echocardiograms, either begin or stop):A diagnosis can also help identify necessary medical referrals and screening for associated complications. For example, a glycogen storage disorder would require dietary management via administration of complex carbohydrates3.

Provide information for family members:Identification of a clinically significant finding would allow for a refined risk of recurrence for the parents and targeted, informative testing in other at-risk family members. Also, it would allow for @FNAME@ to better understand the risk to @HIS@ future children.

-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. @FNAME@’s history of *** suggests an underlying genetic cause for @HIS@ hypoglycemia. While detection rates are not known, molecular genetic testing is the most effective method of diagnosis given the wide differential diagnosis.

-If this is a request is for a gene panel, then please describe why a single gene test is not as useful.Gene panel testing is approximately the same price as single gene testing, making this the most cost effective method of diagnosis.

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

1.Ghosh A, Banerjee I and Morris AAM. Recognition, assessment and management of hypoglycaemia in childhood. Arch Dis Child 2016 Jun;101(6):575-80.

2.Kanaka-Gantebein C. Hypoglycemia in childhood: long-term effects. PediatrEndocrinol Rev 2004;1(Suppl. 3):530-6.

3.Bhattacharya K. Investigation and management of the hepatic glycogen storage diseases. TranslPediatr 2015;4(3):240-248.