Prophylactic Cranial Irradiation (PCI)
Radiation Therapy Physician Worksheet
(As of 13 October 2017)
This worksheet is to be used for prophylactic cranial irradiation in a member with small cell lung cancer.
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 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. What is the stage of the lung cancer?
Limited Extensive
What is the status of the primary tumor following therapy?
Complete response (CR)
No response (NR)
Partial response (PR)
a. What technique is planned?
Complex (77307)
3D conformal
Intensity Modulated Radiation Therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct/3D
b. How many fractions will be delivered? Fractions: ___________
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
Note any additional information in the space below: