Dell Whitfield

Needs a human

71 M · MRN TCPT-0047120 · Prostate adenocarcinoma, favorable intermediate risk, cT2a N0 M0

VA Community Care Network Community Care (Federal (VA)) · VA CCN 4471-208-11

Ordered by R. Lee, MD · Sep 15, 2026 · CPT 77523 · C61 Malignant neoplasm of prostate

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Texas Center for Proton Therapy

Prior authorization evidence packet

Proton beam radiation therapy · Cover sheet

ACE

Prepared Sep 29, 2026

0 tabs · 0 pages

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Patient & request

Patient

Dell Whitfield · 71 M

Date of birth

Jun 30, 1955

MRN

TCPT-0047120

Member ID

VA CCN 4471-208-11

Payer / plan

VA Community Care Network Community Care · Federal (VA)

Plan sponsor

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Service

CPT 77523 · Prostate

Diagnosis

C61 · Prostate adenocarcinoma, favorable intermediate risk, cT2a N0 M0

Ordering physician

R. Lee, MD

Order date

Sep 15, 2026

Payer policy

Policy

VA Community Care Network VA-CCN-RO-DEMO

Title

Community Care: Radiation Oncology (Proton) Referral Requirements

Effective

Jan 1, 2026

Snapshot

Demo snapshot, not verified against PolicyBot

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Policy criteria → packet tabs

Required by VA-CCN-RO-DEMO

Key	Requirement	Section	Status	Tab
C-1	Approved community care referral (SEOC)	§1.a	Missing	none
C-2	Histologic confirmation	§2.a	Included	none
C-3	Staging and risk group	§2.b	Included	none
C-4	Comparative photon plan	§3.a	Included	none
C-5	Treating physician plan of care	§4.a	Included	none

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