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Prior Authorization Request Form Genetic Testing for Lynch
Report s e.g. APC gene mutations MSH2 MMR mutations o Clinical findings i.e. pertinent symptoms and duration o Comorbidities o Activity and functional limitations o Family history if applicable o Reason for procedure/test/device when applicable o Pertinent past procedural and surgical history o Past and present diagnostic testing and results o Prior conservative treatments duration and response Consultation and medical clearance report s when applicable Radiology report s and interpretation...
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