| Key | Requirement | Section | Status | Tab |
|---|---|---|---|---|
| C-1 | Histologic confirmation (recurrence biopsy) | §I.A.1 | Included | 1 |
| C-2 | Restaging imaging within 60 days, no distant disease | §I.A.2 | Included | 2 |
| C-3 | Karnofsky performance status ≥ 70 | §I.A.3 | Included | 3 |
| C-4 | Multidisciplinary tumor board recommendation | §I.B.1 | Included | 4 |
| C-5 | Prescription dose and fractionation | §I.C.1 | Included | 5 |
| C-6 | Comparative IMRT plan showing a dosimetric advantage | §I.C.2 | Included | 6 |
| 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 | Not on branch | — |
| C-9 | Prior course: dates, total dose and fractionation | §III.A.1 | Resolved by ACE | 7 |
| C-10 | At least 6 months since the prior course | §III.A.2 | Included | 8 |
| C-11 | Surgical evaluation: salvage surgery not feasible or declined | §III.A.3 | Included | 9 |
| C-12 | Cumulative spinal cord and brainstem dose (composite plan) | §III.B.1 | Missing | none |
| C-13 | Signed letter of medical necessity | §IV.A | Included | 10 |
Histologic confirmation of the recurrence.
Recurrent SCC, left base of tongue (07/30/2026)
“FINAL DIAGNOSIS: Recurrent invasive squamous cell carcinoma, keratinizing, moderately differentiated, left base of tongue.”
Restaging imaging within 60 days showing no distant disease.
rT2 N0 M0 (PET/CT 08/14)
“Locally recurrent left base of tongue carcinoma, rT2 N0. No evidence of distant metastatic disease.”
Documents Karnofsky performance status.
KPS 80
“Functional status: KPS 80 — normal activity with effort”
Multidisciplinary recommendation for re-irradiation.
Tumor board 09/15: salvage re-RT with protons
“Tumor board recommends salvage re-irradiation with proton therapy”
Documents the re-irradiation prescription and plan QA.
60 Gy(RBE) / 30 fx
“Prescription: 60 Gy(RBE) in 30 fractions to CTV-recurrence (GTV + 5 mm, anatomically constrained).”
Comparative IMRT plan showing reduced dose to previously irradiated organs.
Cord Dmax 8.9 vs 21.7 Gy; brainstem 6.2 vs 18.4 Gy (this course)
“Summary: IMPT reduces dose to every previously irradiated organ at risk with equivalent target coverage.”
Primary source for prior course dates, dose, fractionation and site.
Prior RT 70 Gy/35 fx, 04/12–05/28/2021, L oropharynx + neck
“Treatment dates: 04/12/2021 to 05/28/2021. Site: left oropharynx and bilateral neck. Total dose: 70 Gy in 35 fractions (2 Gy per fraction) to gross disease; 56 Gy to elective neck.”
Documents the recurrence, prior treatment history and re-irradiation plan.
Prior course ended May 2021 → ~64 months (inferred)
“She completed chemoradiation in May 2021”
Surgical evaluation: salvage surgery not feasible without major functional loss; declined.
Salvage surgery declined (would require TGL)
“The patient declines salvage surgery after a detailed discussion of functional outcomes.”
Signed letter of medical necessity required by §IV.A.
LMN signed 09/23/2026
“Proton re-irradiation is medically necessary for this patient.”
ACE read 45 documents and omitted 35 as not required by AET-PBRT-DEMO.
| Administrative — not required by policy | 6 |
| Routine labs — not required by policy | 6 |
| Scheduling call — not clinical evidence | 3 |
| Education record — not required by policy | 3 |
| Correspondence — not clinical evidence | 3 |
| Chemotherapy planning — not required by policy | 3 |
| Setup details — not required by policy | 3 |
| Swallow therapy — not required by policy | 2 |
| Prior surveillance visit — not required by policy | 2 |
| Prior hospitalization — not required by policy | 1 |
| Supportive care — not required by this policy | 1 |
| Swallow function baseline — not required by policy | 1 |
| Social history — not required by policy | 1 |