Letter of medical necessity · Clinical Notes
Letter of medical necessity — proton re-irradiation
Sep 23, 2026 · R. Lee, MD · 1 page
G2 › Raman, Priya › Clinical Notes › Radiation Oncology › 2026-09-23 Letter of medical necessity
In packet · tab 10
LETTER OF MEDICAL NECESSITY
Re: Priya Raman, DOB 02/19/1965, Aetna member W284019376
Ms. Raman has a biopsy-proven local recurrence of p16-negative squamous cell carcinoma of the left base of tongue, five years after definitive chemoradiation. Salvage surgery would require total glossectomy and laryngectomy and has been declined. Re-irradiation with protons limits additional dose to the previously irradiated spinal cord, brainstem and larynx. Proton re-irradiation is medically necessary for this patient.C-13
Electronically signed: R. Lee, MD, 09/23/2026 17:40