Radiation Therapy Brain Metastases Request
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.
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First Name: Middle Initial: Last Name:
DOB (mm/dd/yyy y):
Gender: Male Female
Health Plan: Member ID:
Clinical Information
ICD-10 Code(s):
What is the radiation therapy treatment start date (mm/dd/yyyy)?
eviCore is utilizing a clinical decision support submission model for this diagnosis.
Please note that only some of the following example questions will need to be answered during the
submission of your prior authorization request.
For best results, the answers to these questions should be submitted online.
What is the treatment plan?
Whole Brain Radiation Therapy (WBRT)
Hippocampal Avoidance Whole Brain Radiation Therapy (HA-WBRT)
Single Fraction Stereotactic Radiosurgery (SRS) (Linear Accelerator based)
Single Fraction Stereotactic Radiosurgery (SRS) (Gamma Knife based)
Multi-Fraction Stereotactic Radiosurgery (SRS)
Other (including proton based therapies)
Does the patient have any of the following?
Small Cell, Lymphoma or a germ cell tumor
Performance status of ECOG 3 or 4
Leptomeningeal disease
History of prior SRS
Multiple lesions that will be treated sequentially
None of the above
Has the patient received radiation to the brain previously? Yes No N/A
