OpenOnco · Treatment Plan

Treatment plan — Classical Hodgkin Lymphoma

PLAN-CHL-PED-BULKY-001-V1 · v1 · 2026-09-09

Patient

CHL-PED-BULKY-001 · Algorithm: ALGO-CHL-1L

DiagnosisClassical Hodgkin Lymphoma

MOH / ICD-10C81.9

ICD-O-39650/3

StageIIB

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-CHL-1L-ABVD

Regimen

ABVD (Adriamycin + Bleomycin + Vinblastine + Dacarbazine), 2-6 cycles

Drugs + NSZU

Doxorubicin (DRUG-DOXORUBICIN) 25 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered
Bleomycin (DRUG-BLEOMYCIN) 10 units/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered
Vinblastine (DRUG-VINBLASTINE) 6 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered
Dacarbazine (DRUG-DACARBAZINE) 375 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered

Supportive care

SUP-ANTIEMETIC-PREMED

Hard contraindications

CI-LVEF-LOW-FOR-ANTHRACYCLINE

Reason

Primary current-line option selected by ALGO-CHL-1L at step 1.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-CHL-1L-A-AVD

Regimen

A+AVD (Brentuximab vedotin + Adriamycin + Vinblastine + Dacarbazine), 6 cycles

Drugs + NSZU

Brentuximab vedotin (DRUG-BRENTUXIMAB-VEDOTIN) 1.2 mg/kg · IV days 1+15 of 28-day cycle × 6 · IV ✓ NSZU covered
Doxorubicin (DRUG-DOXORUBICIN) 25 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered
Vinblastine (DRUG-VINBLASTINE) 6 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered
Dacarbazine (DRUG-DACARBAZINE) 375 mg/m² · IV days 1+15 of 28-day cycle · IV ✓ NSZU covered

Supportive care

SUP-ANTIEMETIC-PREMED, SUP-GCSF-NEUTROPENIA

Hard contraindications

CI-LVEF-LOW-FOR-ANTHRACYCLINE, CI-BORTEZOMIB-SEVERE-NEUROPATHY, CI-HBV-NO-PROPHYLAXIS

Reason

Current-line alternative presented for HCP consideration

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HIV-SEROLOGY	HIV Antibody/Antigen	Critical	lab	—	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-LN-EXCISIONAL-BIOPSY	Excisional LN Biopsy	Critical	histology	—	all tracks
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	all tracks
TEST-PET-CT	FDG PET/CT (whole body)	Standard	imaging	—	all tracks

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Classical Hodgkin lymphoma stage III-IV (advanced) — selects A+AVD (ECHELON-1) over ABVD if brentuximab accessible
Stage III–IV класичної лімфоми Ходжкіна (поширена стадія) скеровує до A+AVD (ECHELON-1) замість ABVD при доступності брентуксимаб ведотину.
RF-CHL-ADVANCED-STAGESRC-NCCN-BCELL-2025SRC-ESMO-HODGKIN-2024

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Pre-treatment LVEF <50% is an absolute contraindication to anthracycline-containing regimens (R-CHOP, Pola-R-CHP, ABVD, BV-AVD, etc.). Cardiotoxicity from doxorubicin is dose-cumulative and often irreversible; starting with already-impaired function risks acute decompensation.CI-LVEF-LOW-FOR-ANTHRACYCLINE
Severe pre-existing peripheral neuropathy is an absolute contraindication to bortezomib — therapy will likely worsen the neuropathy to a disabling and often permanent extent.CI-BORTEZOMIB-SEVERE-NEUROPATHY
Active or latent HBV without antiviral prophylaxis is an absolute contraindication to starting B-cell-depleting / immunomodulatory monoclonal antibody therapy (anti-CD20, anti-CD30 ADC, anti-CD38). Severe HBV reactivation hepatitis risk including fulminant hepatic failure.CI-HBV-NO-PROPHYLAXIS

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-CHL-1L-ABVD)

Do NOT combine with brentuximab vedotin — ABSOLUTE pulmonary toxicity contraindication.
Do NOT use G-CSF on ABVD — increases pulmonary toxicity of bleomycin.
Do NOT continue bleomycin with DLCO drop ≥25% — switch to AVD (drop bleo).
Do NOT skip baseline LVEF + DLCO + fertility preservation discussion.
Do NOT use high-flow O2 during anesthesia after bleomycin (lifetime risk).
Do NOT start without HBV screening + entecavir prophylaxis if HBsAg+ — reactivation on steroid pulse is real (also actionable if anti-HBc+ — monitor HBV-DNA q-cycle).
Do NOT interrupt ART in HIV+ patients — HIV-HL outcomes approach HIV-negative cHL with concurrent ART; avoid ritonavir-boosted PIs (vincristine interaction); PJP prophylaxis throughout.

Aggressive plan (IND-CHL-1L-A-AVD)

Do NOT combine brentuximab with bleomycin — ABSOLUTE; lethality risk.
Do NOT skip G-CSF support — neutropenia with brentuximab + anti-mitotic is higher.
Do NOT ignore pre-existing peripheral neuropathy — Grade ≥2 = absolute CI.
Do NOT prescribe without a verified funding pathway — brentuximab is not NSZU-reimbursed.
Do NOT start brentuximab without HBV screening + entecavir prophylaxis if HBsAg+ or anti-HBc+ — anti-CD30 ADC has documented HBV reactivation risk; continue ≥12 mo after last BV dose.
Do NOT interrupt ART in HIV+ — A+AVD is acceptable with ART; integrase backbone preferred (vincristine-PI interaction); PJP prophylaxis throughout.

Monitoring schedule

Monitoring schedule by treatment phase

Standard plan · MON-R-CHOP-REGIMEN

Phase	Window	Tests	Checkpoints
Baseline	Within 2 weeks before cycle 1	TEST-CBC, TEST-CMP, TEST-LFT, TEST-LDH, TEST-B2-MICROGLOBULIN, TEST-HBV-SEROLOGY, TEST-HCV-ANTIBODY, TEST-HIV-SEROLOGY, TEST-PET-CT, TEST-LN-EXCISIONAL-BIOPSY, TEST-FLOW-CYTOMETRY, TEST-CD20-IHC, TEST-ECHO, TEST-PREGNANCY, TEST-BM-ASPIRATE, TEST-BM-TREPHINE	Confirm CD20+ DLBCL histology; rule out double-hit (FISH for MYC/BCL2/BCL6) Confirm HBV status + entecavir prophylaxis plan if HBsAg+ or anti-HBc+ Baseline LVEF ≥50% before doxorubicin IPI calculation documented (age, ECOG, LDH, stage, extranodal sites) CNS-IPI calculation if anatomic risk sites or composite score concerning Fertility preservation discussion (sperm banking / oocyte cryo) for childbearing-age
On treatment	Day 1 of every 21-day cycle	TEST-CBC, TEST-CMP, TEST-LFT	ANC ≥1500 + platelets ≥100K before each cycle (delay or G-CSF if not) Neuropathy grade documented (CTCAE) — vincristine modification if ≥2 LVEF re-check after cumulative doxorubicin ~300 mg/m²
Interim response assessment	After cycles 2-4 (interim PET-CT)	TEST-PET-CT, TEST-LDH	Lugano response criteria + Deauville score If Deauville 4-5 with mass progression → consider salvage or trial
End of treatment	After cycle 6 (within 6-8 weeks)	TEST-PET-CT, TEST-CBC, TEST-CMP, TEST-LDH	Confirm CR vs PR vs SD vs PD by Lugano/Deauville Begin survivorship plan: cardiac surveillance schedule, vaccination catch-up, second-cancer screening
Follow-up (short-term)	Every 3 months × 2 years post-treatment	TEST-CBC, TEST-CMP, TEST-LFT, TEST-LDH	Surveillance for relapse (~40% relapse risk by 2 years overall) HBV reactivation monitoring continues for 12 months post anti-CD20
Follow-up (long-term)	Every 6 months years 3-5, then annually	TEST-CBC, TEST-LFT, TEST-ECHO	Late cardiomyopathy screening (LVEF) annually if cumulative dox >300 Annual second-malignancy screening (skin, breast, etc. age-appropriate)

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Baseline

Within 2 weeks before cycle 1

Induction · ABVD (Adriamycin + Bleomycin + Vinblastine + Dacarbazine), 2-6 cycles

28-day cycles × 2-4 (early-stage + ISRT) OR 6 (advanced); response-adapted per interim PET-CT Deauville

Response assessment

After cycles 2-4 (interim PET-CT)

Follow-up

Every 3 months × 2 years post-treatment

Aggressive plan

Baseline

Within 2 weeks before cycle 1

Induction · A+AVD (Brentuximab vedotin + Adriamycin + Vinblastine + Dacarbazine), 6 cycles

28-day cycles × 6

Response assessment

After cycles 2-4 (interim PET-CT)

Follow-up

Every 3 months × 2 years post-treatment

MDT brief

Discussion questions (4, 2 blocking)

BLOCKING OQ-CD20-CONFIRMATION
Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
Anti-CD20 therapy is the backbone of most lines of treatment; absence of CD20 expression fully changes the regimen.
→ pathologist
OQ-STAGING-COMPLETE
Has complete staging been done (Lugano + PET/CT or CT)?
Prognosis and track selection depend on stage and tumor burden.
→ radiologist
OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist
BLOCKING OQ-BIOMARKER-HIV-STATUS
What is the status of HIV status (4th-gen Ag/Ab combo screening) (BIO-HIV-STATUS)? It is required by track(s): IND-CHL-1L-ABVD, IND-CHL-1L-A-AVD. Expected value: any value valid (categorical etiology gate; HIV+ → continue cART throughout, integrase-inhibitor backbone preferred to avoid ritonavir-vincristine interaction; PJP prophylaxis if CD4 < 200).
A treatment-track biomarker requirement is missing from the patient profile; the MDT should verify the test result, method, specimen, and date before relying on this option.
→ medical_oncologist

MDT talk tree (5 steps)

#	Owner	Topic	Action
1	medical_oncologist	Biomarker status BLOCKING	What is the status of HIV status (4th-gen Ag/Ab combo screening) (BIO-HIV-STATUS)? It is required by track(s): IND-CHL-1L-ABVD, IND-CHL-1L-A-AVD. Expected value: any value valid (categorical etiology gate; HIV+ → continue cART throughout, integrase-inhibitor backbone preferred to avoid ritonavir-vincristine interaction; PJP prophylaxis if CD4 < 200).
2	pathologist	Pathology confirmation BLOCKING	Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
3	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
4	radiologist	Staging / disease burden	Has complete staging been done (Lugano + PET/CT or CT)?
5	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (required) — mandatory virtual specialists (1)

Hematologist / oncohematologist required
Lymphoma diagnosis — leading specialty for treatment management.
Owns: OQ-LDH-CURRENT

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Pathologist (general) recommended
Confirm lymphoma histology + assess transformation risk (DLBCL/Richter).
Owns: OQ-CD20-CONFIRMATION

Data quality

Incomplete for default-track review. Default-track review is incomplete until required biomarker gaps are resolved.

Biomarker coverage: 1/2 known (50%), 1 missing, 1 default-track gaps
Missing critical: cd20_ihc_status, lugano_stage
Missing recommended: ldh_ratio_to_uln, fib4_index, pet_ct_date
Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-CHL-FRAILTY-AGE, RF-CHL-INFECTION-SCREENING, RF-CHL-TRANSFORMATION-PROGRESSION

Missing data for doctor action

Priority	Clinical item	Owner	Why it matters	Next action	Blocks
CRITICAL	CD20 IHC status `cd20_ihc_status`	pathologist	Confirms CD20-directed therapy is biologically appropriate.	Verify CD20 IHC result, specimen, method, and report date.	-
CRITICAL	Lugano stage `lugano_stage`	radiologist	Defines lymphoma extent and supports tumor-burden and response-assessment decisions.	Document Lugano stage from PET/CT or contrast CT staging.	-
RECOMMENDED	LDH ratio to ULN `ldh_ratio_to_uln`	medical_oncologist	Supports prognostic scoring and aggressive-biology flags.	Enter LDH with local upper limit of normal.	-
RECOMMENDED	FIB-4 liver fibrosis index `fib4_index`	infectious_disease_hepatology	Screens hepatic fibrosis risk before hepatotoxic therapy or antiviral coordination.	Calculate FIB-4 from age, AST, ALT, and platelet count.	-
RECOMMENDED	PET/CT date `pet_ct_date`	radiologist	Shows whether baseline staging is recent enough for treatment planning and later response comparison.	Document baseline PET/CT date or explain alternative staging modality.	-

Missing biomarker	Label	MDT owner	Default track	Required by	Next action
`BIO-HIV-STATUS`	HIV status (4th-gen Ag/Ab combo screening)	medical_oncologist	yes	IND-CHL-1L-ABVD, IND-CHL-1L-A-AVD	Verify result, method, specimen, and report date before sign-off. Expected/constraint: any value valid (categorical etiology gate; HIV+ → continue cART throughout, integrase-inhibitor backbone preferred to avoid ritonavir-vincristine interaction; PJP prophylaxis if CD4 < 200)

Technical MDT skill metadata (3/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-ECHELON-1-CONNORS-2018: Brentuximab Vedotin with Chemotherapy for Stage III or IV Hodgkin's Lymphoma (2018)
SRC-NCCN-BCELL-2025: NCCN Clinical Practice Guidelines in Oncology: B-Cell Lymphomas (v.2.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-09-09.

NCT	Title	Phase	Status	Sponsor	UA	Signals
NCT07551583	Phase II Study Of Nivolumab Plus AVD In Pediatric, Adolescent, And Young Adult Patients With CHL	PHASE2	RECRUITING	M.D. Anderson Cancer Center	—	Small N (<50) Single country
NCT02797717	Treatment for Classical Hodgkin Lymphoma in Children and Adolescents	NA	RECRUITING	GALIA AVRAHAMI	—	Single country
NCT07209059	PET-Adapted First-Line Therapy With Nivolumab for Advanced Hodgkin Lymphoma	PHASE2	RECRUITING	National Research Center for Hematology, Russia	—	Small N (<50) Single country
NCT06984146	Nivo40-AVD for Advanced Classic Hodgkin Lymphoma	PHASE2	RECRUITING	National Medical Research Radiological Centre of the Ministry of Health of Russia	—	Surrogate endpoint only Single country
NCT05039073	Brentuximab Vedotin and Nivolumab for the Treatment of Relapsed/Refractory Classic Hodgkin Lymphoma Previously Treated With Brentuximab Vedotin or Checkpoint Inhibitors	PHASE2	RECRUITING	Emory University	—	Small N (<50) Surrogate endpoint only Single country
NCT05934084	Lifestyles Implemented-Survivorship Care Plan In Lymphoma Survivors	NA	RECRUITING	Fondazione Italiana Linfomi - ETS	—	Single country
NCT07021989	ctDNA-Guided Therapy for Relapsed/Refractory Hodgkin Lymphoma	PHASE2	RECRUITING	Michael Spinner, MD	—	Small N (<50) Single country
NCT06170489	A Phase III Clinical Study Comparing JS004 Plus Toripalimab With Investigator-Selected Chemotherapy in Patients With PD-(L)1monoclonal Antibody Refractory Classic Hodgkin Lymphoma (cHL)	PHASE3	RECRUITING	Shanghai Junshi Bioscience Co., Ltd.	—	Surrogate endpoint only Single country
NCT06393361	Chidamide Decitabine Plus Anti-PD-1 Antibody for Patients With R/R cHL Who Are Transplant-ineligible or Refused Transplant.	PHASE2	RECRUITING	Chinese PLA General Hospital	—	Surrogate endpoint only Single country
NCT07275216	Pembrolizumab in Combination With Chemotherapy for the Treatment of Frail Hodgkin Lymphoma Patients Ineligible for Standard Treatment	PHASE2	RECRUITING	City of Hope Medical Center	—	Small N (<50) Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan ABVD (Adriamycin + Bleomycin + Vinblastine + Dacarbazine), 2-6 cycles (REG-ABVD)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan A+AVD (Brentuximab vedotin + Adriamycin + Vinblastine + Dacarbazine), 6 cycles (REG-A-AVD)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT07551583 Phase II Study Of Nivolumab Plus AVD In Pediatric, Adolescent, And Young Adult Patients With CHL No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT02797717 Treatment for Classical Hodgkin Lymphoma in Children and Adolescents No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07209059 PET-Adapted First-Line Therapy With Nivolumab for Advanced Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06984146 Nivo40-AVD for Advanced Classic Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05039073 Brentuximab Vedotin and Nivolumab for the Treatment of Relapsed/Refractory Classic Hodgkin Lymphoma Previously Treated With Brentuximab Vedotin or Checkpoint Inhibitors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT05934084 Lifestyles Implemented-Survivorship Care Plan In Lymphoma Survivors No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07021989 ctDNA-Guided Therapy for Relapsed/Refractory Hodgkin Lymphoma No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06170489 A Phase III Clinical Study Comparing JS004 Plus Toripalimab With Investigator-Selected Chemotherapy in Patients With PD-(L)1monoclonal Antibody Refractory Classic Hodgkin Lymphoma (cHL) No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT06393361 Chidamide Decitabine Plus Anti-PD-1 Antibody for Patients With R/R cHL Who Are Transplant-ineligible or Refused Transplant. No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07275216 Pembrolizumab in Combination With Chemotherapy for the Treatment of Frail Hodgkin Lymphoma Patients Ineligible for Standard Treatment No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-09-09.

plan_id: PLAN-CHL-PED-BULKY-001-V1 | version: 1 | generated: 2026-09-09T12:26:41.223762+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.