Radiation Therapy Physician Worksheet
(As of 21 October 2016)
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.
What is the radiation therapy treatment start date (mm/dd/yyyy)?
the intended treatment technique?
is not the intended treatment, do not complete the ‘Bone Metastases – Xofigo
Plan’ physician worksheet. Instead, complete the ‘Bone Metastases’ physician worksheet.
What is patient’s weight? Weight must be recorded in kilograms.
Has the patient ever had, or does the patient currently have, metastases to
a visceral (non-bony/skeletal) site or to lymph nodes?
Has the patient exhausted all medical or surgical ablative hormonal
Is the patient’s serum testosterone currently at castrate levels (less than 50
Is the patient exhibiting prostate specific antigen (PSA) progression [2
consecutive rises in PSA, at least 1 week apart, within the past 6 months]?
What was the date and result of the patient’s last PSA (within the last 30 days)?
Date: _____ /_____ / ______
a. Was a bone scan performed within the past 60 days?
b. If a bone scan was performed within the past 60 days, what status did the bone scan reveal?