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

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

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Other Cancer Type
Radiopharmaceuticals
Radiation Therapy Worksheet
(As of 25 March 2019)
This worksheet is to be used for treatment involving Radiopharmaceuticals. If external beam radiation therapy is being
planned for treatment of the liver, please use the appropriate cancer type worksheet. If the request is for SIRT or Xofigo,
please use the appropriate physician worksheet.
Radiopharmaceuticals should be used by or under the control of physicians who are qualified by specific training and
experience in the safe use and handling of radiopharmaceuticals, and whose experience and training have been approved
by the appropriate governmental agency authorized to license the use of radiopharmaceuticals.
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.
1
Patient name:
What is the radiopharmaceutical start date (mm/dd/yyyy)?
_____ /______ /_______
1.
Which radiopharmaceutical will be used?
Iodine-131 (I-131)
Lutetium-177 (Lu-177 ; Lutathera
®
)
Ibritumomab Tiuxetan (Zevalin
®
)
Strontium-89 (Sr-89)
Samarium-153 (Sm-153)
Iobenguane I-131 (Azedra
®
)
If Lutetium-177 (Lu-177 ; Lutathera
®
) was selected, please continue to page 2.
If Iobenguane I-131 (Azedra
®
) was selected, please continue to page 4.
Otherwise, please submit the following with this completed worksheet.
1. Consult Note
Lutetium-177 (Lu-177 ; Lutathera®)
Radiation Therapy Worksheet
(As of 25 March 2019)
Lutathera is indicated for the treatment of somatostatin receptor-positive gastroenteropancreatic and
bronchopulmonary neuroendocrine tumors.
2
1.
Yes No
2.
Yes No
3.
Yes No
4.
Yes No
5.
Does the individual have one of the following?
Metastatic disease
Locally advanced inoperable disease
Other: ________________
6.
Is the individual progressing on current therapy?
Yes No
7.
______________
8.
______________
9.
______________
10.
______________
11.
______________
12.
______________
13.
______________
14.
Yes No
15.
Yes No
Continued on next page
Lutetium-177 (Lu-177 ; Lutathera®)
Radiation Therapy Worksheet
(As of 25 March 2019)
Lutathera is indicated for the treatment of somatostatin receptor-positive gastroenteropancreatic and
bronchopulmonary neuroendocrine tumors.
3
Please submit the following with this completed worksheet:
1. Radiation Oncology or Nuclear Medicine Consult Note
2. Documentation of the above lab values
8.
Note any additional information in the space below.
Iobenguane I-131 (Azedra
®
)
Radiation Therapy Worksheet
(As of 25 March 2019)
High-specific-activity (HSA) iobenguane I-131 (Azedra
®
) is approved for the treatment of adult and pediatric
patients 12 years or older with iobenguane scan-positive, unresectable, locally advanced or metastatic
pheochromocytoma or paraganglioma who require systemic anticancer therapy.
4
1.
Yes No
2.
Yes No
3.
Yes No
4.
Yes No
5.
Yes No
6.
______________
7.
______________
8.
______________
9.
______________
10.
______________
11.
______________
12.
Yes No
13.
Yes No
14.
Yes No
15.
______________
Continued on next page
Iobenguane I-131 (Azedra
®
)
Radiation Therapy Worksheet
(As of 25 March 2019)
High-specific-activity (HSA) iobenguane I-131 (Azedra®) is approved for the treatment of adult and pediatric
patients 12 years or older with iobenguane scan-positive, unresectable, locally advanced or metastatic
pheochromocytoma or paraganglioma who require systemic anticancer therapy.
5
Please submit the following with this completed worksheet:
1. Consultation note
2. Documentation of the above lab results
16.
Note any additional information in the space below.
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Other Cancer Type Radiopharmaceuticals Radiation Therapy Worksheet (As (eviCore)

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Completed 23 June 2021

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