REVIEW REQUEST FOR
Diagnostic Genetic Testing of a Potentially Affected
Individual (Adult or Child)
Provider Data Collection Tool Based on Medical Policy GENE.00013
Policy Last Review Date: 02/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 04/15/2014
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:
Home
Outpatient
Other:
Service Requested (CPT if known):
Inpatient
Diagnosis Code(s) (if known):
******Preconceptual or prenatal genetic testing using panels of genes (with or without next generation sequencing),
including but not limited to whole genome and whole exome sequencing, is considered investigational and not medically
necessary unless all components of the panel have been determined to be medically necessary. However, individual
components of a panel that meet the appropriate criteria may be considered medically necessary.
Please check all that apply to the individual:
Request is for Genetic testing for diagnostic purposes
Check all that apply to the individual:
Individual has symptoms of a genetic disorder
Individual is at risk for a late onset genetic disorder or slowly evolving genetic disorder
Individual has melanoma (hereditary)
Individual has amyotrophic lateral sclerosis (ALS, also known as Lou Gehrig's disease)
Individual has ataxia telangiectasia
Other (please list):
Check all that apply:
A specific mutation, - set of mutations, or gene expression profile has been established in the scientific literature to be
reliably associated with the disease
A biochemical or other test is identified but the results are indeterminate
The genetic disorder cannot be identified through biochemical or other testing
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REVIEW REQUEST FOR
Diagnostic Genetic Testing of a Potentially Affected
Individual (Adult or Child)
Provider Data Collection Tool Based on Medical Policy GENE.00013
Policy Last Review Date: 02/25/2010
Policy Effective Date: 04/21/2010
Provider Tool Effective Date: 05/26/2010
The results of the genetic test could impact the medical management of the individual with a resulting improvement in
health outcomes
Testing is accompanied by genetic counseling.
Other (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 the health plan or its
designees 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.
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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