Fillable Head or Neck Cancer Radiation Therapy Physician Worksheet (eviCore)

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Head or Neck Cancer Radiation Therapy Physician Worksheet (eviCore)

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Head or Neck Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
This worksheet is to be used for curative or palliative treatment of head and neck cancer. If the treatment is for metastases
from head and neck 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.
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)?
_____ /______ /______
1.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
2.
Lip and oral cavity
Pharynx
Larynx
Nasal cavity and para-nasal sinuses
Thyroid
Mucosal melanoma of head and neck
Occult/unknown primary
Major salivary gland
Other: _________________________
3.
T0
T1
T2
T3
T4
N0
N1
N2a
N2b
N2c
N3
4.
Definitive
Palliative
Post-operative
Isolated locoregional recurrence
Pre-operative
Salvage therapy
Continued on next page
Continued on next page
Head or Neck Cancer
Radiation Therapy Physician Worksheet
(As of 26 January 2017)
5.
What technique will be used to deliver the radiation therapy?
Brachytherapy
External beam radiation therapy (EBRT)
6.
If brachytherapy is the selected technique, then answer the following set of questions:
a. What type of brachytherapy will be used?
High dose rate
Low dose rate
b. What is the implant type?
Interstitial
Intracavitary
7.
If EBRT is the selected technique, then what is the EBRT technique?
Complex (77307)
3D conformal
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT): fixed gantry
Tomotherapy
Rotational arc therapy
Proton beam therapy
8.
Will the patient be receiving concurrent chemotherapy?
Yes No
9.
Will the patient receive treatment twice daily during the course of treatment?
Yes No
10.
Note any additional information in the space below:
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Head or Neck Cancer Radiation Therapy Physician Worksheet (eviCore)

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Completed 23 June 2021

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