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Download Preconceptional or Prenatal Genetic Testing of a Parent
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REVIEW REQUEST FOR Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent Provider Data Collection Tool Based on Medical Policy GENE.00012 Policy Last Review Date: 02/02/2017 Policy Effective Date: 03/29/3017 Provider Tool Effective Date: 04/15/2014 Individual Name: Date of Birth: Insurance Identification Number: Individual 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): ******Preconceptual or prenatal genetic testing using panels of genes (with or without next generation sequencing), including but not limited to whole genome and whole exome sequencing, is considered investigational and not medically necessary unless all components of the panel have been determined to be medically necessary. However, individual components of a panel that meet the appropriate criteria may be considered medically necessary. Please check all that apply to the individual: Request is for preconceptional or prenatal genetic testing of a parent or prospective parent Genetic testing is to determine carrier status of cystic fibrosis Genetic testing is to determine carrier status of amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease) Genetic testing is to determine carrier status of other inherited disorders (If checked, complete both of the following sections) Criteria based on family history Genetic testing is to determine the pattern of inheritance and to guide subsequent reproductive decisions (If checked, complete any of the following that applies) An affected child is identified with either an autosomal recessive disorder, an x-linked disorder, or an inherited disorder with variable penetrance One or both parents or prospective parent(s) have another first or a second degree relative who is affected with either an autosomal recessive disorder, an x-linked disorder, or an inherited disorder with variable penetrance Page 1 of 2 REVIEW REQUEST FOR Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent Provider Data Collection Tool Based on Medical Policy GENE.00012 Policy Last Review Date: 02/02/2017 Policy Effective Date: 03/29/3017 Provider Tool Effective Date: 04/15/2014 One or both parents or prospective parent(s) have a first degree relative who has an affected child with either an autosomal recessive disorder, an x-linked disorder, or an inherited disorder with variable penetrance Other (please specify): ____________ Genetic testing is to determine carrier status and to guide subsequent reproductive decisions (If checked, complete any of the following that applies) The parent or prospective parent is at high risk for a genetic disorder with a late onset presentation The parents or prospective parents are members of an ethnic group with a high risk of a specific genetic disorder with an autosomal recessive pattern of inheritance, including: Tay-Sach's disease Canavan disease Mucolipidosis IV Nieman Pick Disease Type A Fanconi anemia group C Bloom syndrome Gaucher's disease Other inherited disorders (please specify): ____________ Other (please specify): ____________ Criteria for Specific Genetic Test Request is for specific genetic testing in parent or prospective parents for whom: (Check all that apply) A specific mutation, or set of mutations, has been established in the scientific literature to be reliably associated with the disease The genetic disorder is associated with a potentially severe disability or has a lethal natural history A biochemical or other test is identified but the results are indeterminate or the genetic disorder cannot be identified through biochemical or other testing Genetic testing is accompanied by genetic counseling Other (please list):___________________ 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 2 of 2