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REVIEW REQUEST FOR Genetic Testing for Colorectal Cancer Susceptibility Provider Data Collection Tool Based on Medical Policy GENE.00028 Policy Last Review Date: 11/14/2013 Policy Effective Date: 01/14/2014 Provider Tool Effective Date: 01/14/2014 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 Medical Policy GENE.00028 Policy Last Review Date: 11/14/2013 Policy Effective Date: 01/14/2014 Provider Tool Effective Date: 01/14/2014 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 immunohistrochemistry (IHC) Individual tested negative for aMSH2 germline mutation Other (please describe): Other (please describe): Familial Adenomatous Polyposis (FAP) Request is for genetic testing to detect mutations in the Familial Adenomatous Polyposis (FAP) genes for an individual with: (check all that apply) Greater than 20 adenomatous colonic polyps during their lifetime First-or second-degree relatives diagnosed with Familial Adenomatous Polyposis (FAP) First-or second-degree relatives with a known FAP gene mutation 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): Genetic Susceptibility Panels for Colorectal Cancer Request is for genetic susceptibility panels: (check all that apply) ColoNext™ Other (please describe): Page 2 of 3 REVIEW REQUEST FOR Genetic Testing for Colorectal Cancer Susceptibility Provider Data Collection Tool Based on Medical Policy GENE.00028 Policy Last Review Date: 11/14/2013 Policy Effective Date: 01/14/2014 Provider Tool Effective Date: 01/14/2014 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