Certificate of Medical Necessity
Genetic Testing for Hereditary Breast or Ovarian Cancer
Please fax completed CMN forms and other required documentation
(i.e., physician history and physical to include family history).
Statewide Fax Number:1.813.806.1233
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:
Telephone Number:
State:
ZIP:
Fax Number:
Contact Name:
Lab Information
Name:
BCBSF Number:
National Provider Identifier (NPI):
Street Address:
City:
County:
Telephone Number:
State:
ZIP:
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?
Certificate of Medical Necessity: Genetic Testing for Hereditary Breast or Ovarian Cancer (i.e. BRCA Testing)
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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?
1. 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.
2. 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.
3. 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.
4. 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.
5. 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:
a.
At least 2 of these 3 relatives must be first or second degree relatives
with breast or ovarian cancer AND
b.
At least one first or second degree relative must have breast cancer
before the age of 50.
Certificate of Medical Necessity: Genetic Testing for Hereditary Breast or Ovarian Cancer (i.e. BRCA Testing)
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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-.
Certificate of Medical Necessity: Genetic Testing for Hereditary Breast or Ovarian Cancer (i.e. BRCA Testing)
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