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

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

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Gallbladder Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of gallbladder cancer. If the treatment is for metastases
from gallbladder 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,
Yes No
2.
What is the treatment intent?
Palliative
Definitive
Post-operative (adjuvant)
Pre-operative (neo-adjuvant)
3.
If post-operative is the treatment intent, then answer the following questions:
a. What is the clinical T stage?
T0
T1
T2
T3
T4
Tis
b. What is the nodal status?
N0
N1
N2
c. What is the resection margin status?
Negative margins
Positive margins
N/A
4.
What technique will be used to deliver the radiation therapy?
External beam radiation therapy (EBRT)
Brachytherapy
Selective internal radiation therapy (SIRT)
Continued on next page
Gallbladder Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
5.
If EBRT is the selected treatment, then answer the following questions:
a. 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 I Phase II
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Number of fractions: ______ Number of fractions: ______
b. If a form of IMRT was selected, was 3D conformal technique considered? Yes No
c. Will daily Image-guided radiation therapy (IGRT) be used? Yes No
6.
If brachytherapy is the selected treatment, then answer the following questions:
a. What is the dose rate?
Low Dose Rate High Dose Rate
b. How many applications will be used?
Applications: ________
7.
If SIRT is the selected treatment plan, how many treatments will be
utilized?
Treatments: __________
8. Will the patient receive concurrent chemotherapy?
Yes No
9.
Note any additional information in the space below. If SIRT or other brachytherapy technique will be
used, provide details and rationale for selection of the SIRT or brachytherapy.
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Gallbladder Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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