Radiation Therapy Skin 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.
What is the type of skin cancer being treated?
Squamous cell carcinoma
Basal cell carcinoma
Merkel cell carcinoma
Mycosis Fungoides
Kaposi’s sarcoma
Other ____________________________________________________
Does the patient have distant metastases disease (stage M1), i.e. to brain,
lung, liver, bone?
Yes No N/A
How many skin lesions are being treated?
Are all skin lesions treated concurrently? Yes No N/A
What is the location of the lesion(s)?
If Melanoma, are you treating regional lymph nodes? Yes No N/A
If Mycosis Fungoides, does the patient have solitary Mycosis Fungoides? Yes No N/A
If Mycosis Fungoides, is this a request for Total Skin Electrons (TSE)? Yes No N/A
If Mycosis Fungoides and TSE, how many fractions of TSE are requested?
If Mycosis Fungoides and TSE, how many areas will be boosted?
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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
Clinical Information
How many fractions will be used for each phase?
Site 1 Site 2 Site 3 Site 4 Treatment Technique
Conventional isodose planning, complex
lectron Beam Therapy
Intensity Modulatd Radiation Therapy (IMRT)
omotherapy (IMRT)
otational Arc Therapy
Proton Beam Therapy
tereotactic Body Radiation Therapy (SBRT) (using photons)
tereotactic Body Proton Therapy (SBPT)
uperficial or Orthovoltage
otal Skin Electrons (TSE)
igh Dose Rate (HDR) Brachytherapy
Electronic Brachytherapy (HDR) (e.g. Xoft, Esteya)
Will image guided radiation therapy (IGRT) be used for treatment? Yes No N/A
Will concurrent chemotherapy be used for this course of treatment? Yes No N/A
If Proton was selected, what technique of Protons will you be using?
Intensity Modulated Proton Therapy (IMRT) (using IMRT planning)
Passive Scattering Proton Therapy (using 3D planning)
Please be prepared to submit consult note, results of imaging from the past 60 days and radiation
prescription or clinical treatment plan in order to expedite the review process. Failure to provide all
relevant information may result in a delay.
Additional Comments/Information: