Continued from above See Attachment B Family History Screening Tool Ashkenazi Jewish ancestry; OR – which is suggested for use prior to ordering BRCA Personal history of ovarian carcinoma Yes any testing (includes fallopian tube and primary BRCA1, BRCA2 gene provider, peritoneal cancers); OR analysis; full sequence except with Note that for the purpose of this policy, a blood “close Personal history of male breast cancer; OR analysis and full valid TAR relative” is defined as a first-degree or second-degree duplication/deletion Personal history of pancreatic cancer; OR override * blood relative. analysis Personal history of metastatic prostate cancer (biopsy-proven and/or with First degree relatives are biological parents, siblings, radiographic evidence; includes distant Continued below and children. Second-degree relatives are biological metastasis and regional bed or nodes; not grandparents, aunts, uncles, nephews, nieces, biochemical recurrence); OR grandchildren and half-siblings. history of high grade prostate third degree blood relatives are mentioned, they cancer (Gleason score at any age with: ≥7) include great-grandparents, great-aunts, One or more close blood relatives (first, great-grandchildren, and first cousins. second or third degree) with ovarian carcinoma, pancreatic cancer or metastatic prostate cancer at any age or breast cancer under 50 years of age; or Two or more close blood relatives (first-, second- or third-degree relatives on the same side of family) with breast or prostate cancer (any grade) at any age; or Ashkenazi Jewish ancestry; OR pathogenic/likely pathogenic variation detected by tumor profiling on any tumor type in the absence of germline pathogenic/likely pathogenic variant analysis; OR an individual without history of breast or ovarian cancer, but with one or more first- or second-degree blood relative meeting any of the above criteria; OR
Continued from above BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis Continued below Yes Ashkenazi Jewish ancestry; OR Personal history of ovarian carcinoma (includes fallopian tube and primary peritoneal cancers); OR Personal history of male breast cancer; OR Personal history of pancreatic cancer; OR Personal history of metastatic prostate cancer (biopsy-proven and/or with radiographic evidence; includes distant metastasis and regional bed or nodes; not biochemical recurrence); OR history of high grade prostate cancer (Gleason score ≥7) at any age with: One or more close blood relatives (first, second or third degree) with ovarian carcinoma, pancreatic cancer or metastatic prostate cancer at any age or breast cancer under 50 years of age; or Two or more close blood relatives (first-, second- or third-degree relatives on the same side of family) with breast or prostate cancer (any grade) at any age; or Ashkenazi Jewish ancestry; OR pathogenic/likely pathogenic variation detected by tumor profiling on any tumor type in the absence of germline pathogenic/likely pathogenic variant analysis; OR an individual without history of breast or ovarian cancer, but with one or more first- or second-degree blood relative meeting any of the above criteria; OR any provider, except with valid TAR override * See Attachment B – Family History Screening Tool which is suggested for use prior to ordering BRCA testing Note that for the purpose of this policy, a “close blood relative” is defined as a first-degree or second-degree blood relative. First degree relatives are biological parents, siblings, and children. Second-degree relatives are biological grandparents, aunts, uncles, nephews, nieces, grandchildren and half-siblings. third degree blood relatives are mentioned, they include great-grandparents, great-aunts, great-grandchildren, and first cousins.