Radiation Therapy Prostate 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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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.
Is radiation being delivered as:
Initial treatment for a newly diagnosed prostate cancer without distant metastatic disease
Post-prostatectomy adjuvant therapy due to adverse pathology without distant metastatic disease
Post-prostatectomy salvage therapy due to recurrence without distant metastatic disease
Palliative therapy (i.e. non-curative therapy to alleviate obstructive symptoms or bleeding)
Other (e.g. Recurrent prostate cancer, Definitive treatment of prostate in the metastatic setting)
What is/was the patient’s risk group (as defined by NCCN
®
)?
Very Low-risk (T1c and Gleason <= 6 and PSA under 10 ng/mL and 1-2 Positive Cores with <=50%
involvement in each core and PSA density < 0.15 ng/mL/g)
Low-risk (T1-T2a and Gleason <= 6 and PSA under 10 ng/mL)
Favorable Intermediate-risk (T2b-T2c or PSA 10-20 ng/mL; Gleason (3+4) and <50% of cores are
positive)
Unfavorable Intermediate-risk (T2b-T2c and/or PSA 10-20 ng/mL; and Gleason (4+3))
High-risk (T3a or Gleason 8-10 or PSA > 20)
Very High-risk (T3b-T4 or > 4 Cores of Gleason 8-10 or Primary Gleason 5)
Regional (any T, N1, M0)
Distant metastases (i.e. spread to bone)
If high-risk or very high-risk, will the pelvic lymph nodes be treated? Yes No N/A
