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REVIEW REQUEST FOR Gene Expression Profiling for Managing Breast Cancer Treatment Provider Data Collection Tool Based on Medical Policy GENE.00011 Policy Last Review Date: 05/13/2010 Policy Effective Date: 07/07/2010 Provider Tool Effective Date: 04/13/2011 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: Service Requested (CPT if known): Place of Service: Outpatient Home Inpatient Other: Diagnosis (ICD-9) if known): Please check all that apply to the individual: Request is for gene expression profiling for managing breast cancer treatment using: (check all that apply) Oncotype™ DX breast cancer assay Breast Cancer Gene Expression Ratio (also known as Theros H/ISM) Insight® DX Breast Cancer Profile MammaPrint® (also referred to as the "Amsterdam signature") The 76-gene "Rotterdam signature" assay The 41-gene signature assay Mammostrat THEROS Breast Cancer IndexSM Other (please list): Individual meets the following criteria: (check all that apply) Individual has had surgery Full pathological evaluation of the specimen has been completed Histology is predominantly (check one): Ductal Lobular Mixed Metaplastic Tubular Colloid Other (please list): Individual is (check all that apply) REVIEW REQUEST FOR Gene Expression Profiling for Managing Breast Cancer Treatment Provider Data Collection Tool Based on Medical Policy GENE.00011 Policy Last Review Date: 05/13/2010 Policy Effective Date: 07/07/2010 Provider Tool Effective Date: 04/13/2011 Estrogen receptor positive (ER+) Estrogen receptor negative (ER-) Progesterone receptor positive (PR+) Progesterone receptor negative (PR-) HER2 receptor positive HER2 receptor negative Other (please list): Tumor staging is (check all that apply) pN0 (node negative) pN1mi with axillary lymph node micrometastasis less than or equal to 2mm Tumor is less than 0.6 cm Tumor size 0.6-1.0 cm moderate/poorly differentiated Tumor size 0.6-1.0 cm and well-differentiated with any of the following unfavorable features:angiolymphatic invasion or high nuclear grade or high histologic grade Tumor size greater than 1.0 cm and less than or equal to 4.0 cm Tumor size is greater than 4.0 cm Other (please list): Individual does not have a pT4 lesion Chemotherapy is being considered as a therapeutic option Chemotherapy will be supervised by the practitioner ordering the gene expression profile Others (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.