Other Cancer Type
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.
What is the radiopharmaceutical start date (mm/dd/yyyy)?
Which radiopharmaceutical will be used?
Lutetium-177 (Lu-177 ; Lutathera
Ibritumomab Tiuxetan (Zevalin
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