Download Fax Number

Certificate of Medical Necessity
Assays of Genetic Expression in Tumor Tissue as a Technique to
Determine Prognosis in Patients with Breast Cancer (Oncotype DX™)
Fax this completed Certificate of Medical Necessity form along with other
required documentation including: physician history and physical, pathology
report, treating physician visit notes that include documentation that the
intention to treat or not treat with adjuvant chemotherapy would be contingent,
at least in part, on the results of the test for the individual patient in question.
Statewide Fax Number:1-813-806-1233
Section A
Physician Information
Name:
BCBSF Number:
National Provider Identifier (NPI):
Street Address:
City:
County:
Telephone Number:
State:
ZIP:
Fax Number:
Contact Name:
Lab Information
Name:
BCBSF Number:
National Provider Identifier (NPI):
Street Address:
City:
County:
Telephone Number:
State:
ZIP:
Fax Number:
Contact Name:
Member Information
Last Name:
First Name:
Member/Contract Number (alpha and numeric):
Date of Birth:
Age:
Weight:
Procedure Information
Procedure Code:
Procedure Description:
ICD-9 Code:
Diagnosis Description:
Scheduled/Tentative Procedure Date:
Section B
Complete ALL of the following questions
Yes
No
Is the requested service a gene expression test other than Oncotype DX
(such as MammaPrint, Mammostrat or THEROS Breast Cancer Index)?
Yes
No
Is breast cancer a new diagnosis (6 months or less)?
Certificate of Medical Necessity: Assays of Genetic Expression in Tumor Tissue as a
Technique to Determine Prognosis in Patients with Breast Cancer (Oncotype DX™)
1
Are ALL of the following criteria met?
Yes
No
Is the tumor unilateral, non-fixed?
Yes
No
Is the tumor node-negative (lymph nodes with micrometastases
(< 2mm in size) are considered node negative)?
Yes
No
Is the tumor hormone-receptor-positive (ER-positive or PR-positive)?
Yes
No
Is the tumor HER2-negative?
Yes
No
Is the tumor size > 0.5 cm?
Yes
No
Will the patient be treated with hormonal therapy?
Yes
No
Is the patient a candidate for chemotherapy?
Yes
No
Has the patient had surgery?
Yes
No
Has full pathological examination of the tumor been completed?
Yes
No
Will the test result determine if adjuvant chemotherapy will be used?
Yes
No
Is the test ordered by the treating physician?
Comments:
My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.
Ordering Physician’s Signature:
Certificate of Medical Necessity: Assays of Genetic Expression in Tumor Tissue as a
Technique to Determine Prognosis in Patients with Breast Cancer (Oncotype DX™)
Date:
2