Download Genetic Testing for Cancer Susceptibility

REVIEW REQUEST FOR
Genetic Testing for Cancer Susceptibility
Provider Data Collection Tool Based on Coverage Guideline GENE.00001
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This provider data collection tool addresses genetic testing to determine whether an individual is at risk for the
development of cancer based on a genetic test. This tool includes criteria which may be used to evaluate the
medical necessity of a specific genetic test when there is no other more specific document.
Note: IF the authorization request is for genetic testing specific to any of the malignant conditions below, please refer to the
corresponding medical policy. Do not make these requests using this data collection tool.
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GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility (A provider data collection tool exists for this request)
GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome (A provider data collection tool exists for this
request)
GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility (A provider data collection tool exists for this
request)
GENE.00031 Genetic Testing for PTEN Hamartoma Tumor Syndrome
GENE.00035 Genetic Testing for TP53 Mutations (Li-Fraumeni Syndrome)
Please check all that apply to the individual:
Genetic Counseling (Must be completed)
The individual undergoing genetic testing will receive genetic counseling
Genetic testing is being offered in a setting with adequately trained health care professionals who can provide
appropriate pre- and post-test counseling
Other (please describe):
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REVIEW REQUEST FOR
Genetic Testing for Cancer Susceptibility
Provider Data Collection Tool Based on Coverage Guideline GENE.00001
Policy Last Review Date: 11/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 01/01/2015
Genetic Testing
The individual’s genetic disorder is associated with a potential significant cancer
List the potential cancer type:
The individual’s cancer risk from the genetic disorder cannot be identified through biochemical
or other testing.
A reliable association between a specific mutation, or set of mutations, and the risk of developing a malignancy
has been established in the scientific literature
The results of the genetic test may impact the medical management of the individual
Use of the genetic test results will direct therapy decisions and likely result in an improvement in net health outcomes
Other (please describe):
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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