Fillable Prior Authorization Request Form - Brcavantage (Page 2 of 3) in pdf

Sample Collection Date Member ID Number or Subscriber Social Security Number Date of Birth

Member Name

Risk Criteria Category (Continued):

Members who seek coverage for BRCA1/2 testing for the benefit of OTHER family members must seek

reimbursement of payment from the OTHER family member’s insurance carrier. BRCA analysis for the medical

management of OTHER family members is not a covered benefit for Aetna members.

1 For the purposes of these guidelines, fallopian tube and primary peritoneal carcinoma should be included.

2 The term “breast cancer” includes both invasive and ductal carcinoma in situ (DCIS) breast cancers. Lobular carcinoma

in situ (LCIS) is not included.

3 Close blood relatives include first-degree relatives (i.e. mother, sister, daughter) or second-degree relatives (i.e. aunt,

grandmother, niece), all of whom are on the same side of the family. For affected Medicare members, close relatives

would also include third-degree relatives (i.e. great grandmother, great aunt and first-degree cousin).

4 A limited family history is defined as a member who has fewer than two 1st or 2nd degree female relatives in the same

lineage that lived to age 45. The “limited family history” can occur on either the maternal or paternal side of family. A

three generation pedigree is needed for this category.

5 Two breast primaries in a single individual includes bilateral disease or cases where there are two or more clearly

separate ipsilateral primary tumors.

6 For screening of Ashkenazi Jewish women, a screening panel for the founder mutations common in the Ashkenazi

Jewish population (multisite testing) is considered medically necessary. If founder mutation testing is negative, full gene

sequencing (reflex testing) is considered medically necessary only if member meets any one of the criteria described

above.

7 Validated quantitative risk assessment tools include BRCAPRO, Yale, University of Pennsylvania (UPenn I or UPenn II),

BOADICEA (Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm) and Tyrer-Cuzick (IBIS

Breast Cancer Risk Evaluation Tool).

8 Triple negative breast cancer is when the individual’s breast cancer cells test negative for estrogen receptors (ER-),

progesterone receptors (PR-) and human epidermal growth factor receptors (HER2-).

9 Testing in this scenario is for the specific identified mutation (single site testing).

Medical Management (if member tests positive)

- Prophylactic oophorectomy

- Bilateral

- Tamoxifen Chemoprevention

- Other

- Prophylactic mastectomy

- Bilateral

- Increased breast surveillance

Patient Education

Consistent with the 1997 National Institutes of Health Consensus Statement on guidelines for care of patients with BRCA1

and BRCA2 mutations and American College of Medical Genetics guidelines, prior to testing and follow-up treatment, the

patient must give informed consent in accordance with applicable law. Also consistent with such guidelines, such informed

consent discussions should include at least the following:

1. Clarification of the patient’s increased risk status

5. Limited data regarding efficacy of methods for early

detection and prevention

2. Explanation of how genetics affects cancer

6. Possible psychological and social impact of testing

susceptibility

3. Potential benefits, risk, and limitations of testing

7. Counseling regarding therapeutic options, including

limitations

4. Possible outcomes of testing (e.g., positive, negative,

or uncertain test results)

By signing this form, I certify that the member listed above has given informed consent in accordance with the

guidelines and risks above and that the BRCA analysis will be used to direct the medical management of this

member.

Physician Name and AETNA Provider Number (PLEASE PRINT)

IPA Name and Provider Number

Physician Signature

IPA Address

Physician Address

IPA Telephone Number

Physician Telephone Number

Submit completed Aetna Prior Authorization form, lab requisition form and blood sample to an Aetna contracted lab.

The laboratory will complete the preauthorization process.

* Please Note: Completion of a Prior Authorization Form does not guarantee payment. Payment of covered benefits is subject to the provider's contract, the

member's eligibility on the dates of services rendered and specific provisions of the member's health benefits plan.

46.18-4

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies.

GR-67606-4 (10-14)

Page 2 of 3

Prior Authorization Request Form - Brcavantage Page 2

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