Fillable Pancreatic Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Pancreatic Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Pancreatic Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of pancreatic cancer. If the treatment is for metastases
from pancreatic cancer, 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 treatment start date (mm/dd/yyyy)?
_____ /_____ / ______
1. Does the patient have distant metastases (stage M1) (i.e. to brain,
lung, liver, bone)?
Yes No
2. What is the timing of radiation?
Adjuvant (postoperative)
Neoadjuvant (preoperative)
Definitive (no surgery planned)
Palliative (for relief of symptoms)
3.
What is the T-stage?
T1
T2
T3
T4
4.
What is the N-stage?
N0 N1
5. If surgery was done, which of the following is present?
Negative margins
Positive margins
Gross residual disease
None of the above
N/A
Continued on the next page
Pancreatic Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
6. What external beam radiation therapy (EBRT) technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1
Phase 2
Complex (77307)
3D conformal
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct/3D
Proton beam therapy
Complex (77307)
3D conformal
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct/3D
Proton beam therapy
Number of fractions: _______________
Number of fractions: _______________
7. a. Was chemotherapy given prior to starting radiation?
Yes No
b. If yes, what is the response following chemotherapy?
Complete response (CR)
No response (NR)
Partial response (PR)
Progressive disease (POD)
8. Is chemotherapy being delivered concurrently?
Yes No
9. Is the area to be treated abutting, overlapping, or within a
previously irradiated area?
Yes No
10.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
11.
Note any additional information in the space below.
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Pancreatic Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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