Download Genotype Testing for Genetic Polymorphisms to Determine

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.