Please Check All That Apply to the Member

REVIEW REQUEST FOR Prophylactic Mastectomy Provider Data Collection Tool Based on Medical Policy SURG.00063 Policy Last Review Date: 02/26/09 Policy Effective Date: 04/22/09 Provider Tool Effective Date: 8/10/09

Member Name: Date of Birth: Insurance Identification Number/HCID: Member Phone Number:

Ordering Provider Name & Specialty: Provider ID Number: Office Address: Office Phone Number: Office Fax Number:

Rendering Provider Name & Specialty: Provider ID Number:

Office Address: Office Phone Number: Office Fax Number:

Date/Date Range of Service: Place of Service: Home Inpatient Service Requested (CPT/HCPCS if known): Outpatient Other: Diagnosis (ICD-9) if known):

Please check all that apply to the member:

Member has: Two or more first-degree relatives with breast cancer One first-degree relative and 2 or more second-degree or third-degree relatives with breast cancer One first-degree relative with breast cancer before the age of 45 and another relative with breast cancer One first-degree relative with breast cancer and one or more relatives with ovarian cancer One first-degree relative with bilateral breast cancer Two second- or third-degree relatives with breast cancer and one or more with ovarian cancer One second- or third-degree relative with breast cancer and two or more with ovarian cancer Three or more second- or third-degree relatives with breast cancer Please specify relatives addressed above: Mother; Please list type of cancer: Sister X ; Please list type of cancer: Daughter X ; Please list type of cancer: Aunt X ; Please list type of cancer: Niece X ; Please list type of cancer: Grandmother X ; Please list type of cancer: Grandchild X ; Please list type of cancer: Half sister X ; Please list type of cancer: First cousin X ; Please list type of cancer: Second cousin X ; Please list type of cancer: First cousin once removed X ; Please list type of cancer: Other (please list): X ; Please list type of cancer:

Presence of a BRCA1 or BRCA2 mutation in the patient consistent with a BRCA1 or BRCA2 mutation in a family member with breast or ovarian cancer Presence of lesions associated with an increased cancer risk. Such lesions include atypical hyperplasia and lobular carcinoma in situ (LCIS) Been diagnosed with breast cancer in one breast. Extensive mammographic abnormalities (i.e. calcifications) such that adequate biopsy is impossible. Other (please list): Page 1 of 2 This request is being submitted: Pre-Claim Post–Claim. If checked, please attach the claim or indicate the claim number

By checking this box, I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a routine audit and request the medical documentation to verify the accuracy of the information reported on this form.

______Name of Provider or Provider Representative Completing Form* Date

*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. For some plans utilization review services are provided by Anthem UM Services, Inc., a separate company.