REVIEW REQUEST FOR
Genotype Testing for Genetic Polymorphisms to
Determine Drug-Metabolizer Status
Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010
Policy Last Review Date: 02/05/2015
Policy Effective Date:
04/07/2015
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
04/07/2015
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:
Outpatient
Home
Inpatient
Other:
Diagnosis Code (s) ( if known):
Please check all that apply to the individual:
Human Leukocyte Antigen B*1502 (HLA-B*1502)
Request is for genotype testing for genetic polymorphisms of Human Leukocyte Antigen B*1502 (HLA-B*1502)
to determine the drug-metabolizer status of individuals for whom the use of carbamazepine is being proposed
The individual is of Asian descent
There are no other alternatives to the use of carbamazepine.
CYP2C19 variant of Cytochrome P450
Request is for genotype testing for identification of the CYP2C19 variant of Cytochrome P450 to determine the
drug-metabolizer status
The individual is currently undergoing treatment with clopidogrel and has not been tested
The individual is being evaluated for treatment with clopidogrel
Human Leukocyte Antigen B (HLA-B*5701)
Request is for genotype testing for Human Leukocyte Antigen B (HLA-B*5701) before commencing treatment
with abacavir (Ziagen®) for persons infected with HIV-1.
Hepatitis C virus (HCV) genotype 1a
Request is for genotype testing in hepatitis C virus (HCV) genotype 1a for the presence of the NS3 Q80K
polymorphism before beginning treatment with Olysio™ (simeprevir) plus peginterferon and ribavirin.
REVIEW REQUEST FOR
Genotype Testing for Genetic Polymorphisms to
Determine Drug-Metabolizer Status
Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010
Policy Last Review Date: 02/05/2015
Policy Effective Date:
04/07/2015
Provider Tool Effective Date:
04/07/2015
CYP2D6 variant of Cytochrome P450
Request is for genotype testing for identification of the CYP2D6 variant of Cytochrome P450 to determine the drugmetabolizer status of the individual. (If checked, answer the following that apply)
The individual is being considered for treatment with eliglustat (Cerdelga™)
The individual is diagnosed with Huntington’s disease and is being considered for tetrabenazine (Xenazine ®)
treatment with a dosage greater than 50 mg per day
Other Genetic Polymorphism Related Requests
Request is for use of a testing panel for genetic polymorphisms to determine drug-metabolizer status
(check the requested panel from the list below):
AIBioTech® CardioloGene Genetic Panel
AIBioTech® Pain Management Panel
AIBioTech® PsychiaGene Genetic Panel
AIBioTech® Urologene Panel
Genecept™ Assay
GeneSight® Analgesic
GeneSight® Psychotropic
GeneSight® ADHD
Millennium PGTSM
Proove® Drug Metabolism test panel
Proove® Narcotic Risk test panel
SureGene Test for Antipsychotic and Antidepressant Response (STA2R)
Vysis ALK Break Apart FISH Probe Kit”
Other panel (please list) _____________________
Request is for genotype testing for genetic polymorphisms to determine drug-metabolizer status for individuals
initiating therapy with any of following drugs (check all that apply):
5-fluorouracil (5-FU)
Antidepressants or antipsychotics
Irinotecan
Olysio (simeprevir) plus Sovaldi® (sofosbuvir).
Opioids and narcotics
Phenytoin
Tamoxifen
Warfarin
Other drug (please specify):
Request is for genotype testing for genetic polymorphisms to determine drug-metabolizer status for individuals
by analysis of any of the following enzymes (check all that apply):
Cytochrome P450 (including CYP2C9) [except where noted above]
Dihydropyrimidine dehydrogenase (DPYD)
Leukocyte Antigen B*1502 (HLA-B*1502) [except where noted above]
Thymidylate synthetase (TYMS)
Uridine diphosphate glucuronosyltransfrease 1A1 (UGT1A1)
Vitamin K epoxide reductase subunit C1 (VKORC1)
Other:
REVIEW REQUEST FOR
Genotype Testing for Genetic Polymorphisms to
Determine Drug-Metabolizer Status
Provider Data Collection Tool Based on Anthem Medical Policy GENE.000010
Policy Last Review Date: 02/05/2015
Policy Effective Date:
04/07/2015
Provider Tool Effective Date:
04/07/2015
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.