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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’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 Page 1 of 3 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): Page 2 of 3 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. Page 3 of 3