Whole Exome Sequencing Recommendation Form

This form, along with a three-generation pedigree, copy of the ordering health care professional’s laboratory requisition form, and a copy of your genetics evaluation documentation are required for consideration of this request. Please fax the completed form and required copies to Cigna at 1.855.245.1104.

Note: This form should only be used for whole exome sequencing (WES) recommendations. A separate request form for all other genetic testing recommendations is available on Cigna.com.

Customer (patient) information

• Name:
• Cigna customer ID:
• Date of birth:
• Date of consultation:

Ordering health care professional information

• Name:
• Street address:
• City, State ZIP:
• Specialty:

Taxpayer Identification Number (TIN):

Telephone:

Fax:

Clinical geneticist, genetic counselor, advanced genetics nurse (AGN-BC), genetic clinical nurse (GCN), or advanced practice nurse in genetics (APNG) information (if different from above)

• Name:
• Street address:
• City, State ZIP:
• Telephone:
• Fax:

Rendering laboratory information

• Name:
• Street address:
• City, State ZIP:

Taxpayer Identification Number (TIN):

Telephone:

Fax:

Diagnosis codes

List ICD-10 codes here:

Requested test information

• Test name:
• CPT code(s):
• List price:

Patient’s phenotype is likely genetic as demonstrated by EITHER of the following:

• Multiple abnormalities affecting unrelated organ systems (please specify):

OR

1. TWO of the following FOUR criteria are met:
2. Abnormality affecting a single organ system (please specify):
3. Significant intellectual disability, symptoms of a complex neurodevelopmental disorder (e.g., self-injurious behavior or reverse sleep-wake cycles), or severe neuropsychiatric condition (e.g., schizophrenia, bipolar disorder, Tourette syndrome).
4. Family history strongly implicating a genetic etiology (please specify findings and degree of relationship):
5. Period of unexplained developmental regression (unrelated to autism or epilepsy).

List of differential diagnoses

• Diagnosis:
• Key gene(s) of interest:

Proposed changes to medical management specific to this patient based on WES results

• Recommended genetic tests if WES is NOT performed
• Name:
• List price:
• Recommended follow-up procedures if WES is NOT performed
• Name:
• Frequency:

Please initial below: _______I attest there is no clinically available single gene or panel test that adequately addresses my patient’s symptoms. Page 2

Whole Exome Sequencing Recommendation Form

Recommendation (choose one of the following):

• This individual meets Cigna's Medical Coverage Policy criteria, and I support the testing requested.
• This individual does not meet Cigna's Medical Coverage Policy criteria, but I support the testing requested for the reason(s) listed below (indicate alternate best-practice guidelines that support your recommendation).
• I do not support the recommendation, but do recommend consideration of the following alternative testing (provide explanation below).
• This individual does not meet Cigna's Medical Coverage Policy criteria for the testing requested, and I recommend no genetic testing be performed at this time.

• This individual does NOT meet Cigna's Medical Coverage Policy criteria and has elected NOT to pursue testing at this time (provide explanation below).
• This individual does meet Cigna's Medical Coverage Policy criteria but has elected NOT to pursue testing at this time for reasons outlined below.
• I have no recommendation to make regarding the testing requested for the reason(s) described below.

Reasons or explanation:

By checking this box, I affirm that I am a genetic clinical nurse (GCN), advanced practice nurse in genetics (APNG), board-certified genetic counselor, board-eligible or board-certified clinical geneticist, or have been specifically credentialed by Cigna to perform genetic counseling, and I am not currently employed by a genetic testing laboratory.

By checking this box, I confirm I have attached a three-generation pedigree, copy of the ordering health care professional's lab requisition form, and a copy of my genetic evaluation documentation. I understand authorization may be denied if all documentation is not received.

Signature

Signature:

Date:

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