Fillable Endometrial Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Endometrial Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Endometrial Cancer
Radiation Therapy Physician Worksheet
(As of 13 October 2017)
4
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
by phone.
First Name:
Middle Initial:
Last Name:
DOB (mm/dd/yyyy):
Member ID:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ / _______
1.
Endometrioid
Papillary serous
Clear cell
Carcinosarcoma
2.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
3.
Palliative
Post-operative
Definitive or medically inoperable
4.
What is the FIGO (International Federation of Gynecology and Obstetrics) stage?
Stage IA
Stage IB
Stage IIA
Stage IIB
Stage IIIA
Stage IIIB
Stage IVA
Stage IVB
Stage IIIC
5.
Grade 1
Grade 2
6.
Are any of the following risk factors present?
1. Age is ≥ 60 years
2. Lymphovascular invasion
3. Lower uterine (cervical/glandular) involvement
Yes No
Continued on next page
Endometrial Cancer
Radiation Therapy Physician Worksheet
(As of 13 October 2017)
7.
Will the patient be receiving concurrent chemotherapy?
Yes No
8.
What is the treatment plan?
Brachytherapy
External beam radiation therapy (EBRT)
9.
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) Electronic Brachytherapy
b. How many fractions will be rendered? Fractions: _____
c. What is the implant type?
Tandem only
Vaginal cylinder only
Ovoids only
Tandem and ovoids
Heyman capsules only
Interstitial
10.
IF EBRT is included in the treatment plan, then what EBRT technique will be used to deliver the
radiation therapy? Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1
Phase 2
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Tomotherapy
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Tomotherapy
Number of fractions: _________________ Number of fractions: _________________
11.
Will daily image-guided radiation therapy (IGRT) be used? Yes No
12.
Note any additional information in the space below:
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Endometrial Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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