Fillable Bone Metastases Xofigo Treatment Plan Radiation Therapy Physician (eviCore)

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Bone Metastases Xofigo Treatment Plan Radiation Therapy Physician (eviCore)

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Bone Metastases
Xofigo
®
Treatment Plan
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.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ / ______
1.
Is Xofigo
®
the intended treatment technique?
Yes No
If Xofigo
®
is not the intended treatment, do not complete the ‘Bone Metastases – Xofigo
®
Treatment
Plan’ physician worksheet. Instead, complete the ‘Bone Metastases’ physician worksheet.
2.
What is patient’s weight? Weight must be recorded in kilograms.
Weight: ___________ Kg
3.
Has the patient ever had, or does the patient currently have, metastases to
a visceral (non-bony/skeletal) site or to lymph nodes?
Yes No
4.
Has the patient exhausted all medical or surgical ablative hormonal
treatments?
Yes No
5.
Is the patient’s serum testosterone currently at castrate levels (less than 50
ng/dL)?
Yes No
6.
Is the patient exhibiting prostate specific antigen (PSA) progression [2
consecutive rises in PSA, at least 1 week apart, within the past 6 months]?
Yes No
7.
What was the date and result of the patient’s last PSA (within the last 30 days)?
Date: _____ /_____ / ______
Result:
8.
a. Was a bone scan performed within the past 60 days?
Yes No
b. If a bone scan was performed within the past 60 days, what status did the bone scan reveal?
Progression
Stability
Improvement
Continued on next page
Bone Metastases
Xofigo
®
Treatment Plan
Radiation Therapy Physician Worksheet
(As of 21 October 2016)
9.
by Computed Tomography (CT) or Magnetic Resonance Imaging (MRI)
within the past 6 months?
Yes No
In order to be considered for approval, the following must be submitted: (1) consultation note regarding use
of Xofigo, (2) result of recent bone scan, (3) recent testosterone level, (4) last two PSA results and (5) results
of re-staging (i.e., CT and/or MRI abdomen/pelvis, chest x-ray).
Recommended to submit request via web in order to upload documentation.
10.
Note any additional information in the space below.
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Bone Metastases Xofigo Treatment Plan Radiation Therapy Physician (eviCore)

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Completed 23 June 2021

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