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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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:
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.
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 was the T stage at initial diagnosis?
T1a
T1b
T2b
T2c
T3b
T4
Has the cancer spread to any of the regional lymph nodes (N1 disease)? Yes No N/A
What is the patient’s PSA level (ng/mL)? _________________ng/mL
What is/was the patient’s Gleason score (range: 2 to 10)?
3 + 4 = 7
8
9 or 10
Unknown
If high-risk or very high-risk, will the pelvic lymph nodes be treated? Yes No N/A
