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Transcript
REVIEW REQUEST FOR
Genetic Testing for Breast &/Or
Ovarian Cancer Syndrome
Provider Data Collection Tool Based on Coverage Guideline GENE.00029
Policy Last Review Date: 11/13/2014
Policy Effective Date:
01/01/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
01/01/2015
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):
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):
BRCA1 and BRCA2
Request is for genetic testing for a BRCA1 or BRCA2 mutation
Request is for genetic testing for cancer susceptibility using the BRACAnalysis® Rearrangement test (BART) on
individuals who have had BRCA 1/2 genetic sequence testing, but have negative results from the testing ( please select
below the reason the initial sequence testing (which the results were negative) was completed)
Please check all of the following criteria that apply:
Individual from a family with a known deleterious BRCA1/BRCA 2 mutation
Individual with a personal history of cancer and any one of the following criteria is met (if checked, complete below):
Individual diagnosed with breast cancer prior to age 50
Individual has a history of breast cancer diagnosed at any age and at least 1first-, second-, or third-degree relative
with breast cancer diagnosed at age 50 years or less
Individual has multiple primary breast cancers or bilateral breast cancer
Individual is a male with breast cancer
Individual has triple negative breast cancer diagnosed at age 60 or less
Individual has a history of breast cancer and a first-, second-, or third-degree male relative with breast cancer
Page 1 of 3
REVIEW REQUEST FOR
Genetic Testing for Breast &/Or
Ovarian Cancer Syndrome
Provider Data Collection Tool Based on Coverage Guideline GENE.00029
Policy Last Review Date: 11/13/2014
Policy Effective Date:
01/01/2015
Provider Tool Effective Date:
01/01/2015
Individual has a history of breast cancer and 2 or more first-, second- or third-degree relatives on the same side of
the family with pancreatic cancer
Individual has a history of ovarian, fallopian tube or primary peritoneal cancer
Individual has a history of pancreatic cancer and 2 or more first-, second- or third-degree relatives on the same side
of the family with breast, ovarian, fallopian tube, primary peritoneal or pancreatic cancer
Individual has a history of breast cancer and at least 2 or more first-, second- or third-degree relatives on the same
side of the family with breast cancer
Individual has a history of breast cancer and at least 1 first-, second- or third-degree relative with ovarian, fallopian
tube, or primary peritoneal cancer
The individual is of Ashkenazi Jewish descent and has a history of pancreatic cancer and a first-, second-, or
third-degree relative on the same side of the family with breast, ovarian, fallopian tube, primary peritoneal or
pancreatic cancer
Individual has a history of breast cancer and belongs to a population at risk for specific mutations due to ethnic
background (for example, Ashkenazi Jewish, Icelandic, Swedish, Hungarian or Dutch descent).
Other (please describe):
Individual with a family history of cancer and the relative who would meet any of the following criteria is NOT
available for testing (if checked, complete below)
Individual for whom the test is requested, has a first or second -degree relative who had breast cancer diagnosed
prior to age 50
Individual for whom the test is requested, has a first or second -degree relative with breast cancer diagnosed at any
age and that relative has at least 1first-, second-, or third-degree relative with breast cancer diagnosed at age 50 years
or less
Individual for whom the test is requested, has a first or second -degree relative who had multiple primary breast
cancers or bilateral breast cancer
Individual for whom the test is requested, has a first or second -degree male relative who developed breast cancer
Individual for whom the test is requested, has a first or second -degree relative who had triple negative breast cancer
diagnosed at age 60 or less
Individual for whom the test is requested, has a first or second -degree relative with breast cancer and that relative
has a first-, second-, or third-degree male relative with breast cancer
Individual has a first- or second -degree relative with a history of breast cancer and 2 or more first-, second-, or thirddegree relatives on the same side of the family with pancreatic cancer
Individual has a first- or second -degree relative who has a history of ovarian cancer and 2 or more first-, second-, or
third-degree relatives on the same side of the family with pancreatic cancer
Individual for whom the test is requested, has a first- or second -degree relative who has a history of ovarian,
fallopian tube, or primary peritoneal cancer
Individual has a first- or second -degree relative with a history of pancreatic cancer and 2 or more first-, second-, or
third-degree relatives on the same side of the family with breast, ovarian, fallopian tube, primary peritoneal or
pancreatic cancer
Individual for whom the test is requested, has a first- or second-degree relative with history of breast cancer, and that
relative has at least 2 or more first-, second- or third-degree relatives on the same side of the family with breast
cancer
Individual for whom the test is requested, has a first- or second-degree relative with breast cancer, and that relative
has at least 1 first-, second- or third-degree relative with ovarian, fallopian tube, or primary peritoneal cancer
Individual for whom the test is requested, has a first- or second-degree relative who has a history of breast cancer,
and that relative belongs to a population at risk for specific mutations due to ethnic background (for example,
Ashkenazi Jewish, Icelandic, Swedish, Hungarian or Dutch descent).
The individual for whom the test is requested, has a first- or second-degree relative of Ashkenazi Jewish descent with
a history of pancreatic cancer, and that relative has a first-, second-, or third-degree relative on the same side of the
family with breast, ovarian, fallopian tube, primary peritoneal or pancreatic cancer
Other (please describe):
Page 2 of 3
REVIEW REQUEST FOR
Genetic Testing for Breast &/Or
Ovarian Cancer Syndrome
Provider Data Collection Tool Based on Coverage Guideline GENE.00029
Policy Last Review Date: 11/13/2014
Policy Effective Date:
01/01/2015
Provider Tool Effective Date:
01/01/2015
Individual with a family history of 3 or more first-, second- or third-degree relatives with ovarian, fallopian tube, or
primary peritoneal cancer or breast cancer (at least 1 of which has breast cancer at or before age 50)
Other (please describe):
Genetic Susceptibility Panels
Request is for genetic susceptibility panels: (check all that apply)
BreastNext™
BREVAGgen
DeCode BreastCancer™
OvaNext™
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.
Page 3 of 3