Download Genetic Testing for Cancer Susceptibility

REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Coverage Guideline GENE.00028
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Genetic Counseling (Must be completed for every request)
The individual undergoing genetic testing will receive genetic counseling
The testing is being offered in a setting with adequately trained health care professionals to provide appropriate pre- and
post-test counseling
Other (please describe):
Hereditary Non-Polyposis Colorectal Cancer (HNPCC [Lynch Syndrome])
Request is for genetic testing to detect mutations in the HNPCC genes for an individual with: (check all that apply)
Individual has 2 or more HNPCC-related tumors (colorectal, endometrial, biliary tract, pancreas, ureter or renal pelvis,
ovarian, brain, gastric, or small intestinal cancers, or sebaceous gland adenomas or keratoacanthomas), including
synchronous and metachronous tumors
Individual has a history of colorectal cancer and a first-degree relative with colorectal cancer diagnosed prior to age 50
Individual has a history of colorectal cancer and a first-degree relative with a HNPCC-related cancer diagnosed prior to
age 50
Individual has a history of colorectal cancer and a first-degree relative with colorectal adenoma diagnosed prior to age
40
Individual has colorectal cancer or endometrial cancer diagnosed prior to age 50
Individual had a colorectal adenomas diagnosed prior to age 40
Individual has a first- or second-degree relative with a known HNPCC mutation (Lynch syndrome in family)
Individual has a personal history of colorectal or endometrial cancer and tumor shows high Micro-satellite Instability
(MSI)
Other (please describe):
Page 1 of 3
REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Coverage Guideline GENE.00028
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Request is for genetic testing to detect mutations in the HNPCC genes and the individual has a family history of potentially
HNPCC related cancer and the relative who would meet any of the following criteria is NOT available for testing:
(check all that apply)
Individual for whom the test is requested, has a first- or second-degree relative with 2 or more HNPCC-related
tumors, (colorectal, endometrial, biliary tract, pancreas, ureter or renal pelvis, ovarian, brain, gastric, or small
intestinal cancers, or sebaceous gland adenomas or keratocanthomas), including synchronous and metachronous
tumors
Individual for whom the test is requested, has a first- or second-degree relative with a history of colorectal cancer
and that relative has a first-degree relative with colorectal cancer diagnosed prior to age 50
Individual for whom the test is requested, has a first- or second-degree relative with a history of colorectal cancer
and that relative has a first-degree relative with a HNPCC-related cancer diagnosed prior to age 50
Individual for whom the test is requested, has a first- or second-degree relative with a history of colorectal cancer
and that relative has a first-degree relative with colorectal adenoma diagnosed prior to age 40
Individual for whom the test is requested, has a first- or second-degree relative with colorectal cancer or
endometrial cancer diagnosed prior to age 50
Individual for whom the test is requested, has a first- or second-degree relative with a colorectal adenoma
diagnosed prior to age 40
Other (please describe):
Request is for genetic testing for EPCAM mutations to make a diagnosis of Lynch syndrome for an individual with
colorectal or endometrial cancer (check all that apply)
Tumor is negative for MSH2 and MSH6 expression as demonstrated by (IHC)
Individual tested negative for aMSH2 germline mutation
Other (please describe):
Other (please describe):
Familial Adenomatous Polyposis (FAP) and Attenuated FAP (AFAP)
Request is for genetic testing to detect mutations in the APC (adenomatous polyposis coli) gene for an individual with:
(check all that apply)
Greater than 10 adenomatous colonic polyps during their lifetime
First-or second-degree relatives diagnosed with Familial Adenomatous Polyposis (FAP)
First-or second-degree relatives diagnosed with AFAP
First-or second-degree relatives with a known APC gene mutation
Individual has a personal history of a desmoid tumor
Other (please describe):
Other (please describe):
MYH (Human MutY homolog)-associated Polyposis (MAP)
Request is for genetic testing for MYH (also known as MUTYH)-associated polyposis (MAP) in for an individual with:
(check all that apply)
Individual has greater than 10 adenomatous colonic polyps and (check all that apply)
A recessive inheritance (family history positive only for siblings)
Undergone testing for adenomatous polyposis coli (APC) with negative results
Individual has greater than 15 cumulative adenomas in 10 years and (check all that apply)
A recessive inheritance (family history positive only for siblings)
Undergone testing for adenomatous polyposis coli (APC) with negative results
Individual is asymptomatic and has a sibling with known MYH-associated polyposis (MAP).
Other (please describe):
Other (please describe):
Page 2 of 3
REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Coverage Guideline GENE.00028
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Genetic Susceptibility Panels for Colorectal Cancer
Request is for genetic susceptibility panels: (check all that apply)
ColoNext™
Other (please describe):
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the medical documentation to verify the accuracy of the information
reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
Page 3 of 3