Cervical Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of cervical cancer. If the treatment is for metastases from
cervical 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 start date (mm/dd/yyyy)? _____ /______ /______
1. Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
Yes No
2.
a. What is the treatment intent?
Post-operative
Definitive
Locoregional recurrence
b. If post-operative is the treatment intent, are any of the following risk
Yes No
2. Deep Stromal invasion
3. Lymphovascular invasion
5. Positive Surgical Margin
6. Positive Parametrium
c. If definitive is the treatment intent, what is the patient’s initial FIGO (International Federation of
Gynecology and Obstetrics) stage?
Stage IA1
Stage IIA1
Stage IIA2
Stage IB1
Stage IIB
Stage IB2
3. Will the para-aortic nodes be treated? Yes No
4. Is gross adenopathy present? Yes No
