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

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

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Esophagus Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
This worksheet is to be used for curative or palliative treatment of esophagus cancer. If the treatment is for metastases
from esophagus 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.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung, liver,
bone)?
Yes No
2.
What is the location of the tumor?
Cervical
Upper thoracic
Mid thoracic
Lower thoracic/GEJ
3.
What is the clinical or pathologic T-stage?
T1a
T2
T3
T4a
T4b
4.
What is the clinical or pathologic N-stage?
N0
N1
N2
N3
5.
What is the treatment intent?
Preoperative (neo-adjuvant)
Definitive (no surgery planned)
Postoperative (adjuvant)
Palliative (for relief of symptoms)
Continued on next page
Esophagus Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
6.
What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
Brachytherapy and EBRT
7.
If EBRT is included in the treatment plan, then answer the following set of questions:
a. What is the treatment technique?
Select a technique for each applicable phase and fill in the number fractions.
Phase 1 Phase 2 Phase 3
3D conformal
3D conformal
3D conformal
Complex treatment (77307)
(DVH not medically
necessary)
Complex treatment (77307)
(DVH not medically
necessary)
Complex treatment (77307)
(DVH not medically
necessary)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy Proton beam therapy Proton beam therapy
Rotational arc therapy Rotational arc therapy Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Tomotherapy Tomotherapy Tomotherapy
Fractions: ______________ Fractions: ______________ Fractions: ______________
8.
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)
b. How many fractions will be rendered? Fractions: __________
9.
Will the patient receive concurrent chemotherapy?
Yes No
10.
Is the area to be treated abutting or overlapping a previously irradiated area?
Yes No
11. Will daily image-guided radiation therapy (IGRT) be used?
Yes No
Continued on next page
Esophagus Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
12. Note any additional information in the space below:
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Completed 23 June 2021

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