| Key | Requirement | Section | Status | Tab |
|---|---|---|---|---|
| C-1 | Histologic confirmation of malignancy | §I.A.1 | Included | none |
| C-2 | Primary site and HPV/p16 status | §II.B.1 | Not on branch | — |
| C-3 | Clinical stage (TNM) documented | §I.A.2 | Included | none |
| C-4 | Definitive (curative) treatment intent | §II.B.2 | Included | none |
| C-5 | Performance status ECOG 0–2 | §I.A.3 | Included | none |
| C-6 | Multidisciplinary tumor board review | §I.B.1 | Included | none |
| C-7 | Prescription dose and fractionation | §III.A.1 | Included | none |
| C-8 | Comparative IMRT plan submitted | §III.B.1 | Included | none |
| C-9 | Mean ipsilateral parotid dose, proton vs IMRT | §III.B.2 | Not on branch | — |
| C-10 | Dental evaluation before radiation | §III.C.1 | Not on branch | — |
| C-11 | Signed physician attestation of medical necessity | §IV.A | Included | none |
| C-12 | Re-irradiation: prior course dates, dose and interval | §II.C.1 | Not on branch | — |
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.