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.
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 treatment intent?
If post-operative is the treatment intent, then answer the following questions:
a. What is the clinical T stage?
b. What is the nodal status?
c. What is the resection margin status?
What technique will be used to deliver the radiation therapy?
External beam radiation therapy (EBRT)
Selective internal radiation therapy (SIRT)