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REVIEW REQUEST FOR Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010 Policy Last Review Date: 02/02/2017 Policy Effective Date: 03/29/2017 Provider Tool Effective Date: 08/10/2015 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 Code (s) ( if known): This data collection tool is for provider request for medical necessity review request for genotype testing for polymorphisms which can identify variants of specific genes associated with abnormal and normal drug metabolism. NOTE: Requests for testing hiopurine methyltransferase (TPMT) in individuals receiving treatment with azathioprine or 6-mercaptopurine therapy, and testing for NS3 Q80K in individuals being treated for Hepatitis C virus are not addressed in this policy and should not be made using this tool. Please check all that apply to the individual: Human Leukocyte Antigen B*1502 (HLA-B*1502) Request is for genotype testing for genetic polymorphisms of Human Leukocyte Antigen B*1502 (HLA-B*1502) to determine the drug-metabolizer status of individuals for whom the use of carbamazepine is being proposed The individual is of Asian descent There are no other alternatives to the use of carbamazepine. CYP2C19 variant of Cytochrome P450 Request is for genotype testing for identification of the CYP2C19 variant of Cytochrome P450 to determine the drug-metabolizer status The individual is currently undergoing treatment with clopidogrel and has not been tested Clopidogrel treatment is being proposed. REVIEW REQUEST FOR Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010 Policy Last Review Date: 02/02/2017 Policy Effective Date: 03/29/2017 Provider Tool Effective Date: 08/10/2015 Human Leukocyte Antigen B (HLA-B*5701) Request is for genotype testing for Human Leukocyte Antigen B (HLA-B*5701) before commencing treatment with abacavir (Ziagen®) for persons infected with HIV-1. CYP2D6 variant of Cytochrome P450 Request is for genotype testing for identification of the CYP2D6 variant of Cytochrome P450 to determine the drug-metabolizer status of the individual being considered for treatment with eliglustat (Cerdelga™) Request is for genotype testing for identification of the CYP2D6 variant of Cytochrome P450 to determine the drug-metabolizer status of the individual diagnosed with Huntington’s disease (If checked, mark the following IF it applies) Individual is being considered for tetrabenazine (Xenazine®) treatment with a dosage greater than 50 mg per day Other Genetic Polymorphism Related Requests Request is for genotype testing for genetic polymorphisms to determine drug-metabolizer status for individuals initiating therapy with any of following drugs (check all that apply): 5-fluorouracil (5-FU) Antidepressants or antipsychotics Irinotecan Opioids and narcotics Phenytoin Tamoxifen Warfarin Other drug (please specify): Request is for genotype testing for genetic polymorphisms to determine drug-metabolizer status for individuals by analysis of any of the following enzymes (check all that apply): Cytochrome P450 (including CYP2C9) [except where noted above] Dihydropyrimidine dehydrogenase (DPYD) Leukocyte Antigen B*1502 (HLA-B*1502) [except where noted above] Thymidylate synthetase (TYMS) Uridine diphosphate glucuronosyltransfrease 1A1 (UGT1A1) Vitamin K epoxide reductase subunit C1 (VKORC1) Other: Request is for use of a testing panel for genetic polymorphisms to determine drug-metabolizer status (check the requested panel from the list below): AIBioTech® CardioloGene Genetic Panel AIBioTech® Pain Management Panel AIBioTech® PsychiaGene Genetic Panel AIBioTech® Urologene Panel Genecept™ Assay GeneSight® Analgesic GeneSight® Psychotropic GeneSight® ADHD Millennium PGTSM Proove® Drug Metabolism test panel Proove® Narcotic Risk test panel SureGene Test for Antipsychotic and Antidepressant Response (STA2R) Vysis ALK Break Apart FISH Probe Kit” Other panel (please list) _____________________ REVIEW REQUEST FOR Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010 Policy Last Review Date: 02/02/2017 Policy Effective Date: 03/29/2017 Provider Tool Effective Date: 08/10/2015 This request is being submitted: Pre-Claim Post–Claim. If checked, please attach the claim or indicate the claim number I confirm that the information entered on this form is accurate and complete based on the records available at the time of this request. I understand the health plan or its designees may request 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.