REVIEW REQUEST FOR
Preconceptional or Prenatal Genetic Testing of a Parent
or Prospective Parent
Provider Data Collection Tool Based on Medical Policy GENE.00012
Policy Last Review Date: 02/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 04/15/2014
Individual Name:
Date of Birth:
Insurance Identification Number:
Individual 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:
Service Requested (CPT if known):
Place of Service:
Home
Outpatient
Other:
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 preconceptional or prenatal genetic testing of a parent or prospective parent
Genetic testing is to determine carrier status of cystic fibrosis
Genetic testing is to determine carrier status of amyotrophic lateral sclerosis (ALS, Lou Gehrig’s disease)
Genetic testingis to determine carrier status of other inherited disorders (If checked, complete both of the following
sections)
Criteria based on family history
Genetic testing is todetermine the pattern of inheritance and to guide subsequent reproductive decisions
(If checked, complete any of the following that applies)
An affected child is identified with either an autosomal recessive disorder, an x-linked disorder, or an
inherited disorder with variable penetrance
One or both parents or prospective parent(s) have another first or a second degree relative who is affected
with either an autosomal recessive disorder, an x-linked disorder, or an inherited disorder with variable penetrance
One or both parents or prospective parent(s) have a first degree relative who has an affected child with either
an autosomal recessive disorder, an x-linked disorder, or an inherited disorder with variable penetrance
Page 1 of 2
REVIEW REQUEST FOR
Preconceptional or Prenatal Genetic Testing of a Parent
or Prospective Parent
Provider Data Collection Tool Based on Medical Policy GENE.00012
Policy Last Review Date: 02/13/2014
Policy Effective Date: 01/01/2015
Provider Tool Effective Date: 04/15/2014
Other (please specify): ____________
Genetic testing is to determine carrier status and to guide subsequent reproductive decisions
(If checked, complete any of the following that applies)
The parent or prospective parent is at high risk for a genetic disorder with a late onset presentation
The parents or prospective parents are members of an ethnic group with a high risk of a specific genetic
disorder with an autosomal recessive pattern of inheritance, including:
Tay-Sach's disease
Canavan disease
Mucolipidosis IV
Nieman Pick Disease Type A
Fanconi anemia group C
Bloom syndrome
Gaucher's disease
Other inherited disorders (please specify): ____________
Other (please specify): ____________
Criteria for Specific Genetic Test
Request is for specific genetic testing in parent or prospective parents for whom: (Check all that apply)
A specific mutation, or set of mutations, has been established in the scientific literature to be reliably
associated with the disease
The genetic disorder is associated with a potentially severe disability or has a lethal natural history
A biochemical or other test is identified but the results are indeterminate or
the genetic disorder cannot be identified through biochemical or other testing
Genetic 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.
Page 2 of 2