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.
First Name:
Middle Initial:
Last Name:
DOB (mm/dd/yyyy):
Member ID:
What is the radiation therapy start date (mm/dd/yyyy)?
1.
For which diagnosis type is the member receiving radiation therapy?
Acoustic neuroma (vestibular schwanoma)
AVM (arteriovenous malformation)
Cavernous malformation
Chordoma
Langerhans cell histiocytosis
Meningioma
Pituitary adenoma
Other CNS benign tumor:_______________
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
Orbital myositis
Osteoarthritis
Paraganglioma
Peyronie disease
Pigmented villonodular synovitis
Plantar fasciitis
Pterygium
Rotator cuff syndrome
Rosai-dorfman disease
Splenomegaly (not always a benign etiology)
Tendonitis
Tennis elbow
Thymoma
Vertebral hemangioma
Other non-cranial/skin benign condition:
_______________________________
