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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 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 Page 1 of 2 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. Page 2 of 2