Radiation Therapy Physician Worksheet
(As 14 April 2017)
This worksheet is to be used for curative or palliative treatment of rectal cancer. If the treatment is for metastases from
rectal cancer, please use the appropriate metastatic worksheet.
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.
What is the radiation therapy treatment start date (mm/dd/yyyy)?
What is the timing of radiation?
Adjuvant radiation (post-operative) following local excision (e.g. Transanal, Kraske)
Adjuvant radiation (post-operative) following transabdominal resection (LAR or APR)
Initial primary treatment/ definitive (no surgery planned)
Local recurrence/ persistence
What is the clinical T stage?
What is the nodal status?
a. Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
b. If the patient has metastatic disease, is he/she planned to undergo
surgical resection of the metastases?
Were any of the following high risk features evident on the pathologic specimen?
Lymphovascular space invasion
Poorly differentiated tumors
No high risk features