Nadia Haddad
Needs a human
52 F · MRN TCPT-0048188 · Maxillary sinus SCC, pT4a N0, post maxillectomy
Aetna Open Access PPO (Commercial) · W301877254
Ordered by R. Lee, MD · Sep 23, 2026 · CPT 77525 · C31.0 Malignant neoplasm of maxillary sinus
| Key | Requirement | Section | Status | Tab |
|---|---|---|---|---|
| C-1 | Histologic confirmation (recurrence biopsy) | §I.A.1 | Included | none |
| C-2 | Restaging imaging within 60 days, no distant disease | §I.A.2 | Included | none |
| C-3 | Karnofsky performance status ≥ 70 | §I.A.3 | Included | none |
| C-4 | Multidisciplinary tumor board recommendation | §I.B.1 | Missing | none |
| C-5 | Prescription dose and fractionation | §I.C.1 | Included | none |
| C-6 | Comparative IMRT plan showing a dosimetric advantage | §I.C.2 | Included | none |
| C-7 | HPV/p16 status (newly diagnosed oropharynx) | §II.A.1 | Not on branch | — |
| C-8 | Parotid and oral cavity sparing (no prior RT) | §II.A.2 | Included | none |
| C-9 | Prior course: dates, total dose and fractionation | §III.A.1 | Not on branch | — |
| C-10 | At least 6 months since the prior course | §III.A.2 | Not on branch | — |
| C-11 | Surgical evaluation: salvage surgery not feasible or declined | §III.A.3 | Not on branch | — |
| C-12 | Cumulative spinal cord and brainstem dose (composite plan) | §III.B.1 | Not on branch | — |
| C-13 | Signed letter of medical necessity | §IV.A | Included | none |
ACE has not built this packet. Build it from the case to resolve the policy, pull evidence from the chart and assemble the numbered tabs.