Fillable Non Cancerous Radiation Therapy Worksheet (As of 29 (eviCore)

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Non Cancerous Radiation Therapy Worksheet (As of 29 (eviCore)

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Non Cancerous
Radiation Therapy Worksheet
(As of 29 January 2020)
If the treatment is for metastases from a non-cancerous (not malignant) condition, 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.
For which diagnosis type is the member receiving radiation therapy?
Benign cranial requests
Acoustic neuroma (vestibular schwanoma)
AVM (arteriovenous malformation)
Cavernous malformation
Chordoma
Craniophayngioma
Langerhans cell histiocytosis
Benign non-skin requests
Bursitis
Carotid body tumor (see chemodectoma)
Castleman disease
(giant lymph node hyperplasia)
Chemodectoma (carotid, glomus jugulare, aortic)
Choroidal hemangioma
Desmoid tumor
Dupuytren’s contracture
Glomus jugulare
Glomus tympanicum
Glomus vagale
Gorham-stout syndrome
(disappearing bone syndrome)
Graves ophthalmopathy
Gynecomastia
Hypertrophic ossification (before or after surgery)
Langerhans cell histiocytosis
Macular degeneration
Continued on next page
Non Cancerous
Radiation Therapy Worksheet
(As of 29 January 2020)
Benign cranial functional requests
Epilepsy
Parkinson’s disease
Psychiatric disorders
Trigeminal neuralgia
Other CNS functional:___________________
Benign skin requests
Keloid scar
Psoriasis
Other benign skin:_____________________
2.
What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
3.
If EBRT is the selected treatment plan, then answer the following set of questions:
a. What external beam radiation therapy (EBRT) technique will be used?
Electrons
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Superficial or Orthovoltage
Single Fraction Stereotactic Radiosurgery
(SRS) (Linear Accelerator based)
Single Fraction Stereotactic Radiosurgery
(SRS) (Gamma Knife based)
Multi-Fraction Cranial Stereotactic
Radiosurgery (SRS)
Stereotactic body radiation therapy (SBRT)
b. How many fractions will be delivered?
Fractions: _____
c. Will daily image-guided radiation therapy (IGRT) be used?
Yes No
4.
If brachytherapy is the selected treatment plan, then answer the following set of questions:
a. What is the dose rate?
Low dose rate (LDR)
High dose rate (HDR)
b. How many fractions will be delivered?
Fraction: _____
Continued on next page
Non Cancerous
Radiation Therapy Worksheet
(As of 29 January 2020)
5.
Note any additional information in the space below:
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Completed 23 June 2021

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