Fillable Anal Canal Cancer Radiation Therapy Physician Worksheet (As (eviCore)

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Anal Canal Cancer Radiation Therapy Physician Worksheet (As (eviCore)

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Anal Canal Cancer
Radiation Therapy Physician Worksheet
(As of 31 January 2017)
This worksheet is to be used for curative or palliative treatment of anal canal cancer. If the treatment is for metastases from
anal canal 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.
Patient name:
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 clinical T-stage?
Tis
T1
T2
T3
T4
3.
What is the clinical or pathologic N-stage?
N0
N1
N2
N3
4.
What is the treatment intent?
Preoperative (neo-adjuvant)
Definitive (no surgery planned)
Postoperative (adjuvant)
Palliative (for relief of symptoms)
5.
What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
Brachytherapy and EBRT
Continued on next page
Anal Canal Cancer
Radiation Therapy Physician Worksheet
(As of 31 January 2017)
PAGE 2 OF 3
6.
If EBRT is included in the treatment plan, then answer the following set of questions:
a. What is the treatment technique?
Select a technique for each applicable phase and fill in the number of fractions.
Phase 2
Phase 3
3D conformal
3D conformal
Complex treatment (77307)
(DVH not medically
necessary)
Complex treatment
(77307) (DVH not medically
necessary)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Proton beam therapy
Rotational arc therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Tomotherapy
Electrons
Electrons
Fractions: ______________
Fractions: ______________
7.
If brachytherapy is included in the treatment plan, then answer the following set of questions:
a. What is the dose rate?
Low dose rate (LDR)
High dose rate (HDR)
b. How many fractions will be rendered?
Fractions: _____
8.
Will the patient receive concurrent chemotherapy?
Yes No
9.
Is the area to be treated abutting or overlapping a previously irradiated area?
Yes No
10.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
Continued on next page
Anal Canal Cancer
Radiation Therapy Physician Worksheet
(As of 31 January 2017)
PAGE 3 OF 3
12.
Note any additional information in the space below:
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Anal Canal Cancer Radiation Therapy Physician Worksheet (As (eviCore)

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Completed 23 June 2021

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