Download Genetic Testing for Colorectal Cancer Susceptibility GENE

REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Medical Policy GENE.00028
Policy Last Review Date: 11/03/2016
Policy Effective Date: 12/28/2016
Provider Tool Effective Date: 12/28/2016
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:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This medical policy based data collection tool is for medical necessity review request for genetic testing for
individuals who are at higher than average risk for the development of colorectal cancer.
Please check all that apply to the individual:
SECTION 1: The following are REQUIRED before proceeding to a specific testing indication.
The testing is being done in a setting with adequately trained health care professionals to provide appropriate
pre- and post-test counseling
The individual undergoing genetic testing will receive genetic counseling
SECTION 2: Hereditary Non-Polyposis Colorectal Cancer (HNPCC [Lynch Syndrome])
Request is for genetic testing to detect mutations in the HNPCC genes
(If checked, mark any of the following that apply to the individual)
Individual has 2 or more HNPCC-related tumors (colorectal, endometrial, biliary tract, pancreas, ureter
or renal pelvis, ovarian, brain, gastric, or small intestinal cancers, or sebaceous gland adenomas or
keratoacanthomas), including synchronous and metachronous tumors
Individual has a history of colorectal cancer and a first-degree relative with colorectal cancer diagnosed
prior to age 50
Individual has a history of colorectal cancer and a first-degree relative with a HNPCC-related cancer
diagnosed prior to age 50
Individual has a history of colorectal cancer and a first-degree relative with colorectal adenoma
diagnosed prior to age 40
Individual has colorectal cancer or endometrial cancer diagnosed prior to age 50
Individual had a colorectal adenomas diagnosed prior to age 40
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REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Medical Policy GENE.00028
Policy Last Review Date: 11/03/2016
Policy Effective Date: 12/28/2016
Provider Tool Effective Date: 12/28/2016
Individual has a first- or second-degree relative with a known HNPCC mutation (Lynch syndrome in
family)
Individual has a personal history of colorectal or endometrial cancer and tumor shows high Microsatellite Instability (MSI)
Individual has a family history of potentially HNPCC related cancer, when that relative is NOT
available for testing: (If checked, mark any of the following that apply to the individual)
Individual has a first- or second-degree relative with 2 or more HNPCC-related tumors (colorectal,
endometrial, biliary tract, pancreas, ureter or renal pelvis, ovarian, brain, gastric, or small intestinal
cancers, or sebaceous gland adenomas or keratoacanthomas), including synchronous and
metachronous tumors
Individual has a first- or second-degree relative with a history of colorectal cancer and that relative
has a first-degree relative with colorectal cancer diagnosed prior to age 50
Individual has a first- or second-degree relative with a history of colorectal cancer and that relative
has a first-degree relative with an HNPCC-related cancer diagnosed prior to age 50
Individual has a first- or second-degree relative with a history of colorectal cancer and that relative
has a first-degree relative with colorectal adenoma diagnosed prior to age 40
Individual for whom the test is requested, has a first- or second-degree relative with colorectal
cancer or endometrial cancer diagnosed prior to age 50
Individual has a first- or second-degree relative with a colorectal adenoma diagnosed
prior to age 40
Other (please describe):
Request is for genetic testing for epithelial cell adhesion molecule (EPCAM, also known as TACSTD1)
mutations to diagnose Lynch syndrome (If checked, mark all of the following that apply to the individual)
Individual has colorectal or endometrial cancer
The tumor is negative for MSH2 and MSH6 expression as demonstrated by IHC
Individual tested negative for a MSH2 germline mutation
Other (please describe):
SECTION 3: Familial Adenomatous Polyposis (FAP) and Attenuated FAP (AFAP)
Request is for genetic testing to detect mutations in the APC (adenomatous polyposis coli) gene
(If checked, please mark any of the following that apply to the individual)
Individual has greater than 10 adenomatous colonic polyps during their lifetime
First-or second-degree relatives of individuals diagnosed with FAP (Familial Adenopmatour Polyposis)
or AFAP (Attenuated FAP)
First-or second-degree relatives of individuals with a known APC gene mutation
Individual has a personal history of a desmoid tumor
Other (please describe):
SECTION 4: MYH (Human MutY homolog)-associated Polyposis (MAP)
Request is for genetic testing for MYH (also known as MUTYH)-associated polyposis (MAP)
(If checked, mark all of the following that apply to the individual)
The individual has greater than 10 adenomatous colonic polyps
Individual is asymptomatic and has a first-degree relative with known MAP mutation.
Other (please describe):
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REVIEW REQUEST FOR
Genetic Testing for Colorectal Cancer Susceptibility
Provider Data Collection Tool Based on Medical Policy GENE.00028
Policy Last Review Date: 11/03/2016
Policy Effective Date: 12/28/2016
Provider Tool Effective Date: 12/28/2016
SECTION 5: Genetic Susceptibility Panels for Colorectal Cancer
Request is for genetic testing for colorectal cancer susceptibility using panels of genes (with or
without next-generation sequencing), (for example, ColoNext™)
Please specify the gene panel(s) to be used: ______________
Request is for a specific component of a genetic panel not specified above.
If checked, list the panel component requested; _________________
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.
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