Fillable Other Cancer Type Radiation Therapy Worksheet (As of (eviCore)

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Other Cancer Type Radiation Therapy Worksheet (As of (eviCore)

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Other Cancer Type
Radiation Therapy Worksheet
(As of 29 January 2020)
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)? _____ /______ /_______
If your request is for Radiopharmaceuticals, please use the appropriate worksheet.
1.
What is the primary diagnosis?
Adrenal Cancer
Anal Cancer
Bile Duct Cancer
Bladder Cancer
Bone Metastases
Brain Metastases
Breast Cancer
Cervical Cancer
CNS Lymphoma
CNS Neoplasm
Endometrial Cancer
Esophagus Cancer
Gallbladder Cancer
Gastric (Stomach) Cancer
Head and Neck Cancer
Hepatobiliary Cancer
Hodgkin’s Lymphoma
Kidney Cancer
Liver Cancer
Lung Cancer – Non Small Cell
Lung Cancer – Small Cell
Multiple Myeloma
Non-Cancerous Diagnosis
Oligometastases
Pancreatic Cancer
Prostate Cancer
Rectal Cancer
Skin Cancer
Soft Tissue Sarcoma
Testicular Cancer
Urethral and Ureteral Cancer
Vulva Cancer
Metastases (Non-Bone/Brain)
Other
If Other was not selected, please stop and fill out the appropriate physician worksheet.
2.
Please specify the primary diagnosis: ____________________________________________________
Continued on next page
Other Cancer Type
Radiation Therapy Worksheet
(As of 29 January 2020)
3. a. What is the
patient’s
ECOG
performance
status?
0 Fully active, able to carry on all pre-disease performance without restriction.
1
2
3
4
b. If the ECOG status is due to the cancer, is the status
expected to improve with radiation therapy treatment?
Yes No
4. Does the patient have distant metastases (stage M1) (i.e. to
brain, lung, liver, bone)?
Yes No
If the diagnosis is brain or bone metastases, stop and use the brain or bone metastases worksheet.
5. a. What is the intent of treatment?
Initial primary treatment
Pre-operative radiation
Post-operative radiation
Palliation at primary site
Isolated local recurrence at primary or adjacent site
Palliation of metastatic site - explain below in question #5b
Other - explain below in question #5b
b. If intent of treatment is “palliation of metastatic site” or “other”, then use the space below to list the
metastatic sites to be treated and to explain the treatment intent in further detail.
If treatment intent is “palliation at metastatic site”, “palliation at primary site” or “other” (see question
#5a), skip forward to question #9. Otherwise, continue forward to question #6
6.
a. What is the clinical stage?
T1 T2 T3 T4 Unknown
b. Nodes:
N0 N1 N2 N3 Nx
7.
Is the area to be treated abutting or overlapping a previously
irradiated area?
Yes No
8. Will the patient receive concurrent chemotherapy?
Yes No
Continued on next page
Other Cancer Type
Radiation Therapy Worksheet
(As of 29 January 2020)
9
.
a. What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
Brachytherapy and EBRT
Selective internal radiation therapy (SIRT)
b. If SIRT is the selected treatment plan, how many
treatments will be used?
Treatments: _________
If “Selective internal radiation therapy (SIRT)” is the selected treatment plan, skip forward to
question #12. Otherwise, continue forward to question #10
10.
If EBRT is included in the treatment plan, then answer the following set of questions:
a. What is the EBRT technique?
Select a technique for each applicable phase, and fill in the number of fractions
Phase 1 Phase II Phase III
Complex (77307) Complex (77307) Complex (77307)
3D conformal 3D conformal 3D conformal
Electrons Electrons Electrons
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
Rotational arc therapy Rotational arc therapy Rotational arc therapy
Proton beam therapy Proton beam therapy Proton beam therapy
Tomotherapy Tomotherapy Tomotherapy
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Single Fraction Stereotactic
radiosurgery (SRS) (Linear
Accelerator based)
Single Fraction Stereotactic
radiosurgery (SRS) (Linear
Accelerator based)
Single Fraction Stereotactic
radiosurgery (SRS) (Linear
Accelerator based)
Single Fraction Stereotactic
radiosurgery (SRS)
(Gamma Knife based)
Single Fraction Stereotactic
radiosurgery (SRS)
(Gamma Knife based)
Single Fraction Stereotactic
radiosurgery (SRS)
(Gamma Knife based)
Number of fractions: ____ Number of fractions: ____ Number of fractions: ____
b. Will daily image-guided radiation therapy (IGRT) be used? Yes No
Continued on next page
Other Cancer Type
Radiation Therapy Worksheet
(As of 29 January 2020)
11. If brachytherapy is included in the 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 applications will be used? Applications: _______
12. Note any additional information in the space below:
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Completed 23 June 2021

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