Selective Internal Radiation Therapy (SIRT)
Radiation Therapy Worksheet
(As of 09 June 2017)
This worksheet is to be used for treatment of the liver using Yttrium-90 (Y-90) also known as SIRT (selective internal
radiation therapy). If external beam radiation therapy is being planned for treatment of the liver, please use the Liver
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)?
The diagnostic procedure to determine if there is lung shunting should not be requested as SIRT, or
billed using a therapeutic isotope procedure such as SIRT.
For what diagnosis is SIRT being utilized?
Primary liver cancer (please skip forward to question #3)
Metastases to liver
a. What is the primary cancer?
Other cancer: Specify: _____________________________
b. Is the liver metastases the dominant site of metastases?
Is the liver involvement resectable or treatable using a simpler ablative
What is the
Fully active, able to carry on all pre-disease performance without restriction.
Restricted in physically strenuous activity but ambulatory and able to carry out
work of a light or sedentary nature, e.g., light house work, office work.
Ambulatory and capable of all self-care but unable to carry out any work
activities. Up and about more than 50% of waking hours.
Capable of only limited self-care, confined to bed or chair more than 50% of
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
Is life expectancy greater than three (3) months?
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