Download Cardiac Ion Channel Genetic Testing

REVIEW REQUEST FOR
Cardiac Ion Channel Genetic Testing
Provider Data Collection Tool Based on Medical Policy GENE.00007
Policy Last Review Date: 02/02/2017
Policy Effective Date: 03/29/2017
Provider Tool Effective Date: 03/31/2017
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):
This medical policy based data collection tool is for a medical necessity review request for genetic testing of
cardiac ion channel mutations in persons with suspected channelopathies, such as long QT syndrome
(LQTS), in order to determine the risk for sudden cardiac death (SCD).
Please check all that apply to the individual:
Request is for genetic testing for cardiac ion channel mutations for Long QT Syndrome (LQTS)
Testing is to rule out significant increased risk of LQTS and sudden death
Individual to be tested has a first-degree relative (proband*) with a clinical diagnosis of LQTS
The 1st relative with a clinical diagnosis of LQTS is a:
Parent
Sibling
Child
The 1st affected family member (proband) has a confirmed pathogenic genetic mutation for LQTS
Family member (proband) has sustained sudden death
Family member (proband) has sustained an unexplained syncopal episode
Family member (proband) has sustained ventricular fibrillation with successful resuscitation
A mutation confirmatory for LQTS has been identified in the 1st affected family member
(proband) that will be specifically tested for in this potentially at-risk individual
The individual will undergo genetic counseling
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REVIEW REQUEST FOR
Cardiac Ion Channel Genetic Testing
Provider Data Collection Tool Based on Medical Policy GENE.00007
Policy Last Review Date: 02/02/2017
Policy Effective Date: 03/29/2017
Provider Tool Effective Date: 03/31/2017
Request is for genetic testing for cardiac ion channel mutations OTHER THAN LQTS
Testing is for Brugada Syndrome (BrS)
Testing is for Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT)
Testing is for Short QT Syndrome (SQTS)
Other: _________________________
NOTE TO PROVIDER:
First-degree relative: Any relative who is a parent, sibling, or offspring to another
*Proband: A term used in medical genetics to refer to the first affected family member with a known pathogenic
genetic mutation which, in this document, refers to a family member with a known diagnosis of LQTS
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.
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