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COLARIS AP® – SAMPLE LMN #5 For patients with colorectal adenomatous polyps and a negative APC result [Date] ATTN: [Physician Name, M.D.] [Insurance Company/Institution] [Street Address] [City, State, Zip] Re: [Patient Name or ID/Claim Number] Dear Medical Director: I am writing to request coverage for analysis of the APC and MYH genes for __________________________________________________due to a personal history of ________________________________________________________ diagnosed at age(s) ______________________________. The number of adenomatous colorectal polyps detected in this patient (##) thus far, is suggestive of mutations in the MYH gene. Biallelic mutations in the MYH gene are associated with the presence of multiple colorectal adenomas and cancer. In addition, patients may present with extracolonic disease similar to patients with familial adenomatous polyposis (FAP), including duodenal polyposis. Current medical management recommendations suggest that individuals who have inherited two mutations in the MYH gene be managed similarly to individuals who carry an APC gene mutation, including frequent colonoscopies and upper GI endoscopy, with the option of colectomy. Based on the aggressive screening recommendations that result from these risks, I am recommending genetic testing for mutations in the MYH gene to confirm a diagnosis of polyposis. The information gained from genetic testing will have a significant impact on both the patients’ short- and long-term medical management. Mutations in the APC gene have been ruled out in this patient. Mutations in the APC gene are a common cause of adenomatous polyps throughout the colon and rectum. Thank you for your consideration of this case. Please feel free to contact me directly if I can be of any further assistance in your decision for coverage. Sincerely, [Physician Signature]