Radiation Therapy Breast Cancer 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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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy):
Gender: Male Female
Health Plan: Member ID:
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 breast radiation without regional nodal radiation
Partial breast irradiation (PBI) without regional nodal radiation
Whole breast radiation with regional nodal radiation (i.e., axillary, supraclavicular, and/or internal
mammary nodes)
Treatment of bilateral breast cancer
Post-mastectomy radiation therapy (PMRT)
Accelerated partial breast irradiation (APBI)
Intraoperative radiation therapy (IORT)
Radiation to the breast or chest wall with or without regional nodal radiation in a patient with local
recurrence only and no distant metastatic disease
Radiation to the breast or chest wall with or without regional nodal radiation in a patient with a history of
distant metastatic disease (e.g. to the brain, lung, liver, and/or bone)
Re-irradiation of the breast or chest wall with or without regional nodal radiation
Palliative radiation therapy to the breast or chest wall with or without regional nodal radiation
