Fillable 20211213 CSI Hematology- Oncology- Requisition- Form CV R2

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20211213 CSI Hematology- Oncology- Requisition- Form CV R2

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2
5
80 Wes
t
side P
arkway | Alpharetta, GA 30004
Phone 1-800-459-1185 | Fax 1-888-809-9071
Hematopathology Requisition
Date Packaged _____ / _____ / _____
LABORATORY TESTS REQUESTED
Comprehensive Consultation
Comprehensive diagnosis and consultation to include
medically necessary, additional testing as determined by
CSI Laboratories’ medical staff in communication with the
referring physician(s). (Please include patient history)
FISH Analysis (See reverse for panel/probe references)
MDS MPN LLA CLL (w/re )xefl
Mantle cell Follicular ttikruB PCD/MM (w/reflex)
PDGFRA
PDGFRB CML [t(9;22), BCR/ABL1]
Other FISH probes:
Bone Marrow Morphology
Comprehensive Morphology
(Core, Clot & Smears; includes IHC as
medically necessary)
Morphology Only for - Core(s) Clot(s) Smear(s)
Molecular Assays (PCR)
T-Cell (TCR) B-Cell (IGH)
BCR-ABL1 t(9;22) Quant BCL2 t(14;18) PML-RARA t(15;17)
JAK2 V617F ABL1 Kinase KIT D816V mutation
FLT3/NPM1/CEBPA Panel
FLT3
NPM1
CEBPA
Other PCR Assays:
Flow Cytometry
Comprehensive Flow
(Includes additional testing as medically necessary)
Leukemia / Lymphoma
Cytogenetics
Comprehensive Cytogenetics
(Includes additional testing by FISH
as
medically necessary)
Cytogenetics Only
Additional Tests:
CSI Laboratories Use Only:
PNH (Blood only)
Primary / Secondary / Supplemental Policy # Group #
Source / Fixation
#
#
#
#
#
#
Patient Telephone Number
CLIENT IDENTIFICATION PATIENT IDENTIFICATION
Last Name First Name MI
Address City ST ZIP
DOB Age Gender: M / F SSN
Ordering Physician MRN
Treating Physician Specimen ID
BILLING INFORMATION
CLIENT PATIENT
MEDICARE # MEDICAID #
INSURANCE
CLINICAL INFORMATION New Diagnosis Post-Therapy Relapse Remission
Bone Marrow Transplant -
Autologous Allogeneic Sex Mismatch
Hodgkin Lymphoma Myeloproliferative Neoplasms (MPN)
Chronic Lymphoproliferative Disorders (CLPD)
Myelodysplastic Syndrome (MDS)
Plasma Cell Dyscrasia / Multiple Myeloma (PCD/MM)
Other Clinical Data:
Non-Hodgkin Lymphoma B-Cell T-Cell
Acute Leukemia Myeloid Lymphoid
Chronic Myelogenous Leukemia (CML)
ICD-10 Code(s):
THERAPY
Current Therapy
Prior
(>1 month ago) Rituximab
®
Erythropoietin / Other CSF Gleevec
®
Campath
®
Collection Date Time
Bone Marrow
Na-Heparin EDTA Fixed Tissue Core Clot
Blood Na-Heparin EDTA
Smears / Slides
Air-Dried Stained Other
Sme
ar
s submit
t
ed f
or correlation only
*Include recent CBC. In case of dry-tap, send a second core in RPMI and 10ml peripheral blood in NaHep.
*See reverse for additional information
Original and Second Copies (White / Canary) - CSI Laboratories Bottom Copy (Pink) - Client
PAC004-01/09/19
SPECIMEN INFORMATION (Two identifiers are required on requisition & specimen)
Attached face sheet/insurance card
Non-Hospital
(Outreach/Clinic patient) Hospital
(In/Out patient at time of procedure)
2580 Westside Parkway, Alpharetta, GA 30004
P: 1-800-459-1185 | F: 1-888-809-9071
Date packaged:
Hematology Oncology Requisition
CSI_12132021_R2
CLINICAL INFORMATION *
NEXT-GENERATION SEQUENCING
SINGLE-GENE ASSAYS
LABORATORY TESTS REQUESTED
COMPREHENSIVE CONSULTATION
Comprehensive diagnosis and consultaon to include addional medically necessary
tesng as determined by CSI Laboratories’ medical sta in communicaon with
the referring physician(s). Please include paent history.
FISH (see reverse for additional panels/probes and reflex testing)
BONE MARROW MORPHOLOGY
Comprehensive Morphology (Core, Clot & Smears; includes IHC as medically necessary)
Morphology Only for: Core(s) Clot(s) Smear(s)
FLOW CYTOMETRY
Leukemia/Lymphoma
PNH (Blood only)
Authorize additional testing
CYTOGENETICS
Comprehensive Chromosome Analysis
(includes additional testing by FISH and/or PCR as medically necessary)
Chromosome Analysis Only
ADDITIONAL TESTS, COMMENTS OR DIFFERENTIAL DIAGNOSIS
CSI Laboratories Use Only:
CLIENT IDENTIFICATION PATIENT IDENTIFICATION
INSURANCE / BILLING INFORMATION - REQUIRED: Please include face sheet and front/back of paent’s insurance card.
SPECIMEN INFORMATION (Two unique ideners are required on requision & specimen) *
THERAPY *
An-CD38 therapy (e.g. daratumumab)An-CD19 therapy (e.g. blinatumomab)
Erythropoien therapy (e.g. epoein alfa) G-CSF (e.g. lgrasm) Other:
An-CD30 therapy (e.g. brentuximab)An-CD20 therapy (e.g. rituximab)
Prior (> 1 month ago)Current therapy
Original and Second Copy (White / Canary) CSI Laboratories
Boom Copy (Pink) - Client
Hematology Prole: 177 DNA genes (see reverse for specic genes tested)
Hematology PLUS Prole: 177 DNA + 1408 RNA genes (see reverse for specic DNA genes tested)
Liquid Biopsy, Hematology Prole: 177 Genes (full list of genes on reverse)
MOLECULAR
AML Panel CLL/SLL Panel HGBL/Triple-Hit Panel MPN Panel
APL (PML-RARA) CML (BCR-ABL1) Mantle Cell Panel PCD/PCM Panel
B-ALL Panel Eosinophilia Panel Marginal Zone Panel T-ALL Panel
Burki Panel Follicular Panel MDS Panel
Other FISH probes:
AML Mutaon Analysis Panel: FLT3/IDH1/IDH2 *IF karyotype is normal or non-informave,
REFLEX to CEBPA/NPM1; *IF inv(16) or t(8;21), REFLEX to KIT, Exons 8 and 17
BCR-ABL1 follow-up: (select p190 or p210)
B-Cell clonality (IGH reex to IGK)
JAK2 V617F JAK2 reex Exon 12 (PV)
PML-RARA FLT3 IDH1, IDH2
BCR-ABL1 screening p190, p210 (No previous results at CSI)
ABL1 kinase domain mutaon
T-Cell clonality (TCRG reex to TCRB)
JAK2 reex to CALR, MPL (ET, PMF)
KIT (D816V)
IGVH (CLL/SLL)IGH-BCL2 MYD88BRAF (HCL)
Specimen ID: Block ID:
Bone Marrow Asp Na-Heparin EDTA
Smears Air-Dried Fixed Stained
Blood Na-Heparin EDTA
Smears Air-Dried Fixed Stained
Slides Stained Unstained Touch Preps
Other:
Collecon Date: Time:
Include recent CBC report. In case of dry-tap, send a second core in RPMI and
10mL peripheral blood in Sodium Heparin. Two unique ideners are required on
requision & specimen.
Body Site:
(ICD-10 informaon is required)
IDC-10 Code(s):
Physician Noce: Only tests or diagnosc services that are medically necessary should be ordered.
Appropriate ICD-10 informaon must be provided in the specied area above. Payers, including
Medicare and Medicaid, generally do not pay for screening tests. ABN is required for Medicare
paents if ICD-10 codes provided do not support reasoning for tesng.
Autologous Bone Marrow Transplant
New Diagnosis Relapse Remission
Previous Cytogenecs / FISH: Normal Abnormal (Please Provide Report)
Allogeneic Bone Marrow Transplant Donor Sex: Male Female
Other clinical data:
Last Name: First Name: Middle Inial:
Gender: M F DOB: MRN:
Ordering Physician: Treang Physician:
Age:
Hospital status when specimen collected (must choose one): Hospital Outpaent Non-Hospital Outreach / Clinic Paent
Prior Authorizaon Number:
Bill to: Client Bill Insurance Paent/Self Pay Split Bill: Client (TC) and Insurance (PC)
Bill charges to other hospital/facility:
Account Name & C-Number
PLEASE CALL CSI CLIENT SERVICES AT (800) 459-1185 TO INQUIRE ABOUT TESTS NOT LISTED BELOW
SPECIMEN REQUIREMENTS SHIP SPECIMENS WITH COLD PACK
Flow Cytometry
Peripheral Blood 3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Bone Marrow Aspirate 1-2 mL in sodium heparin (green top) - preferred or 1-2 mL in EDTA (purple top)
PNH Prole 3 mL peripheral blood in EDTA (purple top) preferred, should be processed within 24 hours of collecon
Cytogenecs
Peripheral Blood 5 mL in sodium heparin (green top)
Bone Marrow Aspirate 2-3 mL in sodium heparin (green top)
FISH
Peripheral Blood 3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Bone Marrow Aspirate 2-3 mL in sodium heparin (green top) - preferred or 3 mL in EDTA (purple top)
Molecular
Peripheral Blood 5-10 mL EDTA tube (purple top) - preferred; ACD (yellow top) acceptable
Bone Marrow Aspirate 1-2 mL in EDTA tube (purple top) - preferred; ACD (yellow top) acceptable
HEMATOLOGY PROFILE AND LIQUID BIOPSY GENES TESTED FOR ABNORMALITIES
ABL1 BCL2 CBL CDKN2C DICER1 FAS IDH2 KMT2A MPL PAX5 PTCH1 SMAD2 TGFBR2
AKT1 BCL2L1 CBLB CEBPA DNMT3A FBXW7 IGF1R KMT2B MRE11A PBRM1 PTEN SMAD4 TP53
AKT2 BCL6 CBLC CHEK1 EP300 FLT3 IKZF1 KMT2C MTOR PDGFRA PTPN11 SMARCA4 TSC1
AKT3 BCOR CCND1 CHEK2 ERG GATA1 IKZF3 KMT2D MUTYH PDGFRB RAD21 SMARCB1 TSC2
ALK BCORL1 CCND3 CIC ETV6 GATA2 IRF4 KRAS MYC PHF6 RAD50 SMC1A TSHR
AMER1 BCR CD274 CREBBP EZH2 GATA3 JAK1 MAP2K1 MYD88 PIK3CA RAD51 SMO WT1
APC BIRC3 CD79A CRLF2 FAM175A GEN1 JAK2 MAP2K2 NFKBIA PIK3R1 RB1 SOCS1 ZNF217
ARID1A BLM CD79B CSF1R FAM46C GNAQ JAK3 MAP2K4 NOTCH1 PIK3R2 RHOA SRC ZRSR2
ARID1B BRAF CDH1 CSF3R FANCA GNAS KAT6A MAP3K1 NOTCH2 PIM1 RNF43 SRSF2 MEF2B
ARID2 BRCA1 CDK12 CTNNA1 FANCC H3F3A KDM5C MAP3K14 NOTCH3 PLCG1 RUNX1 STAG2
ASXL1 BRCA2 CDK4 CTNNB1 FANCD2 HNF1A KDM6A MAPK1 NPM1 POLD1 SDHB STAT3
ATM BTK CDK6 CUX1 FANCE HOXB13 KDR MCL1 NRAS POLE SETBP1 STK11
ATRX CALR CDKN2A CXCR4 FANCF HSP90AA1 KEAP1 MDM2 NSD1 PPM1D SETD2 TERT
B2M CARD11 CDKN2B DDR2 FANCG IDH1 KIT MDM4 PALB2 PPP2R1A SF3B1 TET2
FISH PANELS: FOR TECH-ONLY SERVICES, REFLEX OPTIONS MUST BE INITIATED BY THE SIGNING PATHOLOGIST
AML - Panel 1 - [t(15;17)/PML-RARA]
*IF NEGATIVE, REFLEX TO: t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, KMT2A(MLL)-Break apart
*IF gain of RARA, REFLEX TO: RARA-Break apart
AML - Panel 2 - [5q/EGR1, 7q/CEP7, CEP8, 20q, RB1-LAMP1, KMT2A(MLL)-Break apart, t(9;22)/BCR-ABL1]
AML - Panel 3 - [5q/EGR1, 7q/CEP7, KMT2A(MLL)-Break apart, t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, t(9;22)/BCR-ABL1]
*IF NEGATIVE, REFLEX TO: RB1-LAMP1, 20q, CEP8
AML - Panel 4 - [t(8;21)/RUNX1T1-RUNX1, inv16/CBFB-Break apart, KMT2A(MLL)-Break apart] - global
AML with monocyc dierenaon - [inv16/CBFB-Break apart, KMT2A(MLL)-Break apart] - global
B – ALL - [ t(9;22)/BCR-ABL1, KMT2A(MLL)-Breakapart, t(12;21)/ETV6-RUNX1, CRLF2-Breakapart, CEP4/CEP10/CEP17] - global
*IF NEGATIVE, REFLEX TO: [9p21/CDKN2A-CEP9, IGH- Breakapart , MYC-Breakapart] - global
*IF gain of ETV6, REFLEX TO: [ETV6-Breakapart] - global
Burki Only - [t(8;14)/IGH-MYC, MYC-Break apart]
*IF GAIN of IGH, REFLEX: [t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF clinically indicated for MCL, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
CLL/SLL + Mantle cell - [CLL1/(ATM/TP53), CLL2/(13q14.3/LAMP1/CEP12),IGH-Break apart, MYB-CEP6, RB1-LAMP1, t(11;14)/CCND1-IGH]
*IF IGH Rearranged, REFLEX: t(14;18)/IGH-BCL2
*IF unresolved queson of MCL, REFLEX: [t(6:14)/CCND3-IGH, CCND1-Break apart, CCND2-Break apart]
CLL/SLL - [CLL1/(ATM/TP53), CLL2/(13q14.3/LAMP1/CEP12),IGH-Break apart, MYB-CEP6, RB1-LAMP1]
*IF IGH Rearranged, REFLEX: [t(11;14)/CCND1-IGH] and/or [t(6:14)/CCND3-IGH, t(14;18)/IGH-BCL2,CCND2-Break apart] if indicated
CML - [t(9;22)/BCR-ABL1]
*IF POSITIVE, REFLEX: (BCR-ABL1(p210/p190) by RT-PCR
Eosinophilia - [PDGFRA-Break apart, PDGFRB-Break apart, FGFR1-Break apart], JAK2-Break apart
Follicular Center Lymphoma - [t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF GAIN IGH, REFLEX: [t(8;14)/IGH-MYC, MYC-Break apart]
*IF queson of MCL by Flow, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
HGBL/Triple Hit - [t(8;14)/IGH-MYC, MYC-Break apart, t(14;18)/IGH-BCL2, BCL6-Break apart, BCL2-Break apart]
*IF clinically indicated for MCL, REFLEX: [t(6:14)/CCND3-IGH, t(11;14)/CCND1-IGH, CCND1-Break apart, CCND2-Break apart]
LPL/Waldenstrom [MYB-CEP6, IGH-Break apart]
MALT Only - [MALT1-Break apart, BCL6-Break apart,t(11;18)/BIRC3-MALT1]
*IF MALT1 rearranged, REFLEX TO: [ t(14;18)/IGH-MALT1]
Marginal Zone - [7q/CEP7, CEP12, BCL6-Break apart, MALT1-Break apart, IGH-Break apart, TP53/CEP17]
*IF MALT1-Break apart rearranged, REFLEX TO: [t(11;18)/BIRC3-MALT1, t(14;18)/IGH-MALT1]
*IF IGH-Break apart rearranged, REFLEX TO: [t(11;14)/CCND1-IGH, CCND1-Break apart, t(14;18)/IGH-BCL2]
*IF unresolved queson of MCL, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
Mantle Cell - [t(11;14)/CCND1-IGH, CCND1-Break apart]
*IF Negave and clinically indicated, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
Mantle cell, Reex CLL/SLL - [t(11;14)/CCND1-IGH,CCND1-Break apart]
*IF NEGATIVE, REFLEX TO: [CLL/SLL Panel]
*IF Negave and clinically indicated, REFLEX: [t(6:14)/CCND3-IGH, CCND2-Break apart]
MDS - [5q/EGR1, 7q/CEP7, CEP8, 20q, RB1-LAMP1, KMT2A(MLL)-Break apart, TP53/CEP17]
MPN - [t(9;22)/BCR-ABL1, 5q/EGR1, 7q/CEP7, CEP8, 9p21/CDKN2A-CEP9, 20q, RB1-LAMP1]
MPN/Eosinophilia - [t(9;22)/BCR-ABL1, 4q12/PDGFRA-Break apart, PDGFRB-Break apart, FGFR1-Break apart], JAK2-Break apart
Plasma Cell Myeloma - [1p/1q, RB1-LAMP1, IGH-Break apart, TP53/CEP17, t(11;14)/CCND1-IGH, CEP9/CEP11]
*IF IGH is rearranged, but Negave for t(11;14)/CCND1-IGH; REFLEX TO: [t(4:14)/FGFR3-IGH, t(6:14)/CCND3-IGH, t(14;16)/IGH-MAF, t(14;20)/IGH-MAFB]
*IF GAIN of CCND1, without GAIN of CEP11, REFLEX: [CCND1-Break apart]
PML-RARA [t(15;17)]
T-ALL - [t(9;22)/BCR-ABL1, (9p21)/CDKN2A-CEP9, KMT2A(MLL)-Break apart]
*IF NEGATIVE, REFLEX TO: [1p33, t(5;14), t(10;11), 7q/CEP734, 14q11.2]
T-PLL [TCL1 for inversion 14 and t(14;14); TRA for t(X;14)]
ADDITIONAL INFORMATION FOR OPTIMAL ANALYSIS:
• Bone marrow smears should not be exposed to formalin vapors from open core/clot biopsy jars.
• Bone marrow smears should be completely air-dried (1-2 hours) prior to packaging in slide holders.
• Please label each specimen with paent name plus two (2) addional unique paent ideners.
• Please include a copy of paent's most recent CBC and clinical history.
• In the event of a dry-tap, please send a second core specimen in RPMI transport media and 10 mL of peripheral blood in sodium heparin for other tesng.
CSI_12132021_R2
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20211213 CSI Hematology- Oncology- Requisition- Form CV R2

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Completed 18 June 2022

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