Radiation Therapy Physician Worksheet
(As of 13 October 2017)
This worksheet is to be used for curative or palliative treatment of endometrial cancer. If the treatment is for metastases
from endometrial 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
What is the radiation therapy treatment start date (mm/dd/yyyy)?
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
What is the intent of treatment?
Definitive or medically inoperable
Isolated locoregional recurrence after surgery
What is the FIGO (International Federation of Gynecology and Obstetrics) stage?
What is the grade of the endometrial cancer?
Are any of the following risk factors present?
1. Age is ≥ 60 years
2. Lymphovascular invasion
3. Lower uterine (cervical/glandular) involvement