Fillable Rectal Cancer Radiation Therapy Physician Worksheet (As 14 (eviCore)

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Rectal Cancer Radiation Therapy Physician Worksheet (As 14 (eviCore)

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Rectal Cancer
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.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ /______
1.
What is the timing of radiation?
Neo-adjuvant (pre-operative)
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
2.
What is the clinical T stage?
T0
T1
T2
T3
T4
3.
What is the nodal status?
Negative
Positive
N/A
4.
Yes No
b. If the patient has metastatic disease, is he/she planned to undergo
surgical resection of the metastases?
Yes No
5.
Were any of the following high risk features evident on the pathologic specimen?
Lymphovascular space invasion
Positive margins
Poorly differentiated tumors
No high risk features
N/A
Continued on next page
Rectal Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
6.
What is the treatment intent?
Definitive
Palliation
7.
What external beam radiation therapy technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase I
Phase II
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Number of fractions: ______
Number of fractions: ______
8.
Will the patient receive concurrent chemotherapy?
Yes No
9.
a. Will daily image-guided radiation therapy (IGRT) be used?
Yes No
b. If IGRT will be used, will the patient be treated in the prone position on
a belly board?
Yes No
10.
Note any additional information in the space below.
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Rectal Cancer Radiation Therapy Physician Worksheet (As 14 (eviCore)

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Completed 23 June 2021

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