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-.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download