CMN - Genetic Testing for Hereditary Breast and Ovarian Cancer
|Certificate of Medical Necessity |[pic] |
|Genetic Testing for Hereditary Breast or Ovarian Cancer |
|Please fax completed CMN forms and other required documentation | |Statewide Fax Number:1.813.806.1233 |
|(i.e., physician history and physical to include family history). | | |
NOTE: Coverage for genetic testing, screening, and counseling are applicable only under those contracts
that include benefits for genetic testing, preventive health services, screening services, and medical counseling.
|Section A |
Physician Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Lab Information
|Name: |BCBSF Number: |National Provider Identifier (NPI): |
|Street Address: |
|City: |County: |State: |ZIP: |
|Telephone Number: |Fax Number: |
|Contact Name: |
Member Information
|Last Name: |First Name: |
|Member/Contract Number (alpha and numeric): |Date of Birth: |Age: |
Procedure Information
|Procedure Code: |Procedure Description: |
|ICD-9 Code: |Diagnosis Description: |
|Scheduled/Tentative Collection Date: |
|Section B |
Complete ALL the following questions. For bulleted questions, check the appropriate indicator(s).
Use the comments field on the last page to provide details.
| Yes No |Is the patient MALE with a personal history of breast cancer? |
| Yes No |Does the patient have a personal history of epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer? |
| Yes No |Was the patient diagnosed at age 45 or younger with or without family history? |
| Yes No |Was the patient diagnosed at age 50 or younger with: |
| | |At least one close blood relative with breast cancer at age 50 or younger OR |
| | |At least one close blood relative with epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer? OR |
| | |Limited family history. |
| Yes No |Was the patient diagnosed at age 60 or younger with a triple-negative breast cancer4? |
| |(See definition of triple negative breast cancer below). |
| Yes No |Was the patient diagnosed with breast cancer diagnosed at any age with: |
| | |Personal history of epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer OR |
| | |Personal history of breast or ovarian cancer at any age with 2 or more close blood relatives with pancreatic cancer at any age OR |
| | |Personal history of pancreatic adenocarcinoma at any age with 2 or more close blood relatives with breast or ovarian or pancreatic|
| | |cancer at any age OR |
| | |At least two close blood relatives with breast cancer or epithelial ovarian cancer, cancer of fallopian tube, or primary |
| | |peritoneal cancer at any age OR |
| | |Two breast primaries in a single individual with at least one close blood relative with breast cancer diagnosed at age 50 years or|
| | |younger; OR |
| | |Two breast primaries in a single individual with at least one close blood relative with epithelial ovarian cancer, cancer of |
| | |fallopian tube, or primary peritoneal cancer; OR |
| | |Two breast primaries, when first breast cancer diagnosis occurred prior to age 50 OR |
| | |Close male blood relative with breast cancer; OR |
| | |At least one close blood relative that has a BRCA1 or BRCA2 mutation; OR |
| | |Ashkenazi Jewish or ethnic groups associated with higher mutation frequency. |
| Yes No |Is the patient WITHOUT a personal history of breast, epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer |
| |with one of the following? |
| | |Individuals with three or more affected first-degree or second-degree1 blood relatives with breast cancer, epithelial ovarian |
| | |cancer, cancer of fallopian tube, or primary peritoneal cancer; irrespective of age at diagnosis. |
| | |Individuals with two first or second-degree1 relatives with: |
| | | |Epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer OR |
| | | |Breast cancer, one of whom was diagnosed at age 50 or younger. |
| | |Individuals with one or more first-degree or second-degree1 relatives with epithelial ovarian cancer, cancer of fallopian tube, or|
| | |primary peritoneal cancer AND one or more first-degree or second-degree1 blood relatives with breast cancer at any age. |
| | |Individuals with one or more first-or second-degree1 relatives with: |
| | | |Multiple primary or bilateral breast cancers in a single individual and another first-degree or second-degree |
| | | |relative with breast cancer diagnosed at age 50 years or younger; OR |
| | | |Multiple primary or bilateral breast cancers in a single individual and another first-degree or second-degree blood |
| | | |relative with epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer OR |
| | | |Close male blood relatives with breast cancer; OR |
| | | |A known BRCA1 or BRCA2 mutation; OR |
| | | |Breast cancer, epithelial ovarian cancer, cancer of fallopian tube, or primary peritoneal cancer at any age in an |
| | | |individual of Ashkenazi Jewish descent. |
| | |Individuals with 3 or more blood relatives (first, second, or third degree) with breast cancer, epithelial ovarian cancer, cancer|
| | |of fallopian tube, or primary peritoneal cancer when all of the following criteria are met: |
| | |At least 2 of these 3 relatives must be first or second degree relatives with breast or ovarian cancer AND |
| | |At least one first or second degree relative must have breast cancer before the age of 50. |
Comments:
| |
My signature below certifies that the information submitted on this form is accurate and these services are medically necessary.
|Ordering Physician’s Signature: |Date: |
Definitions:
1. Close blood relatives include first-, second-, and third-degree relatives. First-degree relatives: children, brothers, sisters and parents. Second-degree relatives: grandparents, aunts, uncles, nieces, nephews, half-siblings, and grandchildren. Third-degree relatives: great-grandparents, great-aunts, great-uncles, great-grandchildren, and first cousins.
2. Male breast cancer qualifies at any age.
3. At least one relative must be a first or second degree relative.
4. Triple-negative breast cancer: describes breast cancer cells that do not have estrogen receptors, progesterone receptors, or large amounts of HER2/neu protein. Also called ER-negative PR-negative HER2/neu-negative and ER-PR-HER2/neu-.
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