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

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

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Kidney Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of kidney cancer. If the treatment is for metastases from
kidney 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 treatment intent?
Pre-operative (neo-adjuvant)
Definitive (no surgery planned)
Post-operative (adjuvant)
3.
What is the clinical T stage?
T0
T1
T2
T3
T4
4. What is the nodal status?
Negative
Positive
5. If the patient has undergone surgical resection, what was the surgical margin status?
Negative
Positive
Continued on the next page
Kidney Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
6.
Phase I Phase II (if applicable)
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: ______
7.
Will the patient receive concurrent chemotherapy?
Yes No
8.
a. Will daily image-guided radiation therapy (IGRT) be used for phase I?
Yes No
b. Will IGRT be used for phase II? Yes No
9. Note any additional information in the space below.
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Kidney Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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