Gastric (Stomach) Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of gastric cancer. If the treatment is for metastases from
gastric 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
a. What is the treatment intent?
Pre-operative (neo-adjuvant)
Post-operative (adjuvant)
Definitive treatment
b. If post-operative is the treatment intent, what is the pathological T stage?
T1
T2
T3
c. If post-operative is the treatment intent, what is the pathological N stage?
N0
d. If post-operative is the treatment intent, does the patient have any of the
following risk factors?
1. Poor differentiation
2. Lymphovascular invasion
3. Perineural invasion
Yes No
