Radiation Therapy Extra-Cranial 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/yyyy):
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 location of the metastatic site(s) that will be treated? Please specify the spine levels and/or other
location for the metastatic site(s) if applicable.
Site 1 Site 2 Site 3 Site 4 Location
Adrenal gland
Bone
Lung
Liver
Spine
Other Non-Bone
Please specify the spine levels, bone location and/or the Other Non-Bone location for the metastatic site(s), if
applicable.
If there are more than 4 metastatic sites, please provide the location(s) of the additional metastatic site(s).
