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REVIEW REQUEST FOR Gene Expression Profiling for Managing Breast Cancer Treatment Provider Data Collection Tool Based on Medical Policy GENE.00011 Policy Last Review Date: 02/26/2009 Policy Effective Date: 04/22/2009 Provider Tool Effective Date: 01/27/2010 Member Name: Date of Birth: Insurance Identification Number: Member 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 member: 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): __________ Member meets the following criteria: (check all that apply) Member 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 Other (please list): __________ Member is (check all that apply) Estrogen receptor positive (ER+) Estrogen receptor negative (ER-) REVIEW REQUEST FOR Gene Expression Profiling for Managing Breast Cancer Treatment Provider Data Collection Tool Based on Medical Policy GENE.00011 Policy Last Review Date: 02/26/2009 Policy Effective Date: 04/22/2009 Provider Tool Effective Date: 01/27/2010 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): __________ Member 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 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. For some plans utilization review services are provided by Anthem UM Services, Inc., a separate company.