Radiation Therapy Non-Small Cell Lung 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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First Name: Middle Initial: Last Name:
DOB (mm/dd/yyy):
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 stage of the lung cancer at the time of original diagnosis?
IIA (T2bN0)
IIB (T3N0)
IIB (T1N1, T2N1)
IIIA
IIIB
IIIC
IV (including oligometastatic disease)
Loco-regional Recurrence
What is the treatment intent?
Curative, No surgery planned or performed
Curative, Post-operative (adjuvant)
Curative, Pre-operative (neo-adjuvant)
Curative, Treatment of the primary in an oligometastatic setting
Palliative (to alleviate symptoms)
