81162 Yes A TAR for code requires documentation of one See Attachment B Family History Screening Tool – or more of the following numbered criteria. is suggested for use prior to ordering BRCA testing BRCA1, BRCA2 gene any analysis; full sequence An individual from a family with a known provider, Note that for the purpose of this policy, a blood deleterious BRCA mutation; OR analysis and full “close except with relative” is defined as a first-degree or second-degree duplication/deletion Personal history of breast cancer (invasive valid TAR blood relative. analysis or ductal carcinoma in situ) plus one or override * more of the following: First degree relatives are biological parents, siblings, Continued below Diagnosed at years of age; OR ≤45 and children. Second-degree relatives are biological Diagnosed at 46 - 50 of age with: grandparents, aunts, uncles, nephews, nieces, grandchildren and half-siblings. An additional breast cancer primary at any age Where third degree blood relatives are mentioned, One or more blood relatives with they include great-grandparents, great-aunts, breast cancer at any age great-grandchildren, and first cousins. One or more close blood relatives with prostate cancer (Gleason score ≥7) An unknown or limited family history; OR Diagnosed at years of age with triple ≤60 negative breast cancer; OR Diagnosed at any age with: One or close blood relatives with: Breast cancer diagnosed at years ≤50 of age; or Ovarian carcinoma; or Male breast cancer; or Metastatic prostate cancer; or Pancreatic cancer Two or more additional diagnosis of breast cancer at any age in patient and/or in close blood relatives; OR Continued
81162 BRCA1, BRCA2 gene analysis; full sequence analysis and full duplication/deletion analysis Continued below Yes A TAR for code requires documentation of one or more of the following numbered criteria. An individual from a family with a known deleterious BRCA mutation; OR Personal history of breast cancer (invasive or ductal carcinoma in situ) plus one or more of the following: Diagnosed at ≤45 years of age; OR Diagnosed at 46 - 50 of age with: An additional breast cancer primary at any age One or more blood relatives with breast cancer at any age One or more close blood relatives with prostate cancer (Gleason score ≥7) An unknown or limited family history; OR Diagnosed at ≤60 years of age with triple negative breast cancer; OR Diagnosed at any age with: One or close blood relatives with: Breast cancer diagnosed at ≤50 years of age; or Ovarian carcinoma; or Male breast cancer; or Metastatic prostate cancer; or Pancreatic cancer Two or more additional diagnosis of breast cancer at any age in patient and/or in close blood relatives; OR Continued any provider, except with valid TAR override * See Attachment B – Family History Screening Tool 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. Where third degree blood relatives are mentioned, they include great-grandparents, great-aunts, great-grandchildren, and first cousins.