Fillable Multiple Myeloma Radiation Therapy Physician Worksheet (As of (eviCore)

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Multiple Myeloma Radiation Therapy Physician Worksheet (As of (eviCore)

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Multiple Myeloma
Radiation Therapy Physician Worksheet
(As of 31 January 2017)
If the treatment is for metastases from multiple myeloma, 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. Is treatment planned for palliation of multiple myeloma?
Yes No
2.
Is treatment planned for a solitary plasmacytoma (either bone or
Yes No
If treatment is not planned for palliation of multiple myeloma or for solitary plasmacytoma, please
stop and use the appropriate worksheet for the patient’s diagnosis.
3.
What is the location/site being treated? ___________________
4.
a. Are you treating a second and/or third site?
Yes No
b. What is the second location/site being treated? ___________________
c. What is the third location/site being treated? ___________________
d. Will sites be treated concurrently? Yes No
Continued on next page
Multiple Myeloma
Radiation Therapy Physician Worksheet
(As of 31 January 2017)
5.
What external beam radiation therapy (EBRT) technique will be used to deliver the radiation therapy?
Select the treatment technique for each site, and fill in the number of gantry angles and fractions.
Site 1 Site 2 Site 3
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Complex (77307)
3D conformal
Intensity modulated
radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation
therapy (SBRT)
Tomotherapy
Electrons
Fractions: ______________ Fractions: ______________ Fractions: ______________
Gantry angles: __________ Gantry angles: __________ Gantry angles: __________
6. What is the
patient’s
ECOG
performance
status?
0
Fully active, able to carry on all pre-disease performance without restriction.
1
Restricted in physically strenuous activity but ambulatory and able to carry out
work of a light or sedentary nature, e.g., light house work, office work.
2
Ambulatory and capable of all self-care but unable to carry out any work
activities. Up and about more than 50% of waking hours.
3
Capable of only limited self-care, confined to bed or chair more than 50% of
waking hours.
4
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
chair.
7. Is the area to be treated abutting, overlapping, or within a previously
Yes No
8.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
9. Note any additional information in the space below.
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Multiple Myeloma Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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