Download Gene Expression Profiling for Managing Breast Cancer

EVIEW REQUEST FOR
Gene Expression Profiling for Managing Breast
Cancer Treatment
Provider Data Collection Tool Based on Medical Policies 2.04.36; GENE.00011
Policy Last Review Date:11/2009; 05/13/2010
Policy Effective Date: 11/2009; 07/07/2010
Provider Tool Effective Date: 03/09/2011
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 (ICD-9) if known):
Please check all that apply to the individual:
Request is for gene expression profiling for managing breast cancer treatment using: (check all that apply)
Oncotype™ DX breast cancer assay
Breast Cancer Gene Expression Ratio (also known as Theros H/ISM)
MammaPrint® (also referred to as the "Amsterdam signature")
The 76-gene "Rotterdam signature" assay
The 41-gene signature assay
Mammostrat
Other (please list):
Individual meets the following criteria: (check all that apply)
Individual has had surgery
Full pathological evaluation of the specimen has been completed
Histology profile is (check all that apply)
Ductal
Lobular
Mixed
Metaplastic
NOT tubular
NOT colloid
EVIEW REQUEST FOR
Gene Expression Profiling for Managing Breast
Cancer Treatment
Provider Data Collection Tool Based on Medical Policies 2.04.36; GENE.00011
Policy Last Review Date:11/2009; 05/13/2010
Policy Effective Date: 11/2009; 07/07/2010
Provider Tool Effective Date: 03/09/2011
Other (please list):
Individual is (check all that apply)
Estrogen receptor positive (ER+)
Estrogen receptor negative (ER-)
Progesterone receptor positive (PR+)
Progesterone receptor negative (PR-)
HER2 receptor positive
HER2 receptor negative
Other (please list):
Tumor staging is (check all that apply)
pN0 (node negative)
pN1mi with axillary lymph node micrometastasis ≤ 2mm
Tumor size 0.6-1.0 cm moderate/poorly differentiated
Tumor size 0.6-1.0 cm well-differentiated with (Check all that apply)
Angiolymphatic invasion
High nuclear grade
High histologic grade
Tumor size >1.0 cm and ≤4.0 cm
Other (please list):
Individual does not have a pT4 lesion
Chemotherapy is being considered as a therapeutic option
Chemotherapy will be supervised by the practitioner ordering the gene expression profile
Others (Please list) :
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 Anthem 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