Fillable Adrenal Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Adrenal Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Adrenal Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of adrenal cancer. If the treatment is for metastases from
adrenal cancer, please use the appropriate metastatic worksheet.
For NON-URGENT requests, please complete this document for authorization along with any relevant clinical
documentation requested within this document (i.e. radiation therapy consultation, comparison plan, etc.) before submitting
the case by web, phone, or fax. Failure to provide all relevant information may delay the determination. Phone and fax
numbers can be found on eviCore.com under the Guidelines and Fax Forms section. You may also log into the provider
portal located on the site to submit an authorization request. URGENT (same day) requests must be submitted by phone.
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy): Member ID:
What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ /______
1.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
2.
What is the treatment intent?
Pre-operative (neo-adjuvant)
Definitive (no surgery planned)
Post-operative (adjuvant)
Palliative (for relief of symptoms)
3.
What is the clinical T stage?
T0
T1
T2
T3
T4
4. What is the nodal status?
Negative
Positive
N/A
5. If the patient has undergone surgical resection, what was the surgical margin status?
Negative
Positive
N/A
Continued on the next page
Adrenal Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
6.
What external beam radiation therapy technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase I Phase II (if applicable)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Number of fractions: ______ Number of fractions: ______
7.
Will the patient receive concurrent chemotherapy?
Yes No
8.
a. Will daily image-guided radiation therapy (IGRT) be used for phase I?
b. Will IGRT be used for phase II? Yes No
9. Note any additional information in the space below.
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Adrenal Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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