Fillable Selective Internal Radiation Therapy (SIRT) Radiation Therapy Worksheet (eviCore)

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Selective Internal Radiation Therapy (SIRT) Radiation Therapy Worksheet (eviCore)

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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
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.
C
Patient name:
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.
1.
For what diagnosis is SIRT being utilized?
Primary liver cancer (please skip forward to question #3)
Metastases to liver
Other
2.
a. What is the primary cancer?
Colorectal cancer
Neuroendocrine cancer
Other cancer: Specify: _____________________________
b. Is the liver metastases the dominant site of metastases?
Yes No
3.
Is the liver involvement resectable or treatable using a simpler ablative
technique?
Yes No
4.
What is the
patient’s
ECOG
performance
status?
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
waking hours.
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
chair.
5.
Is life expectancy greater than three (3) months?
Yes No
Continued on the next page
Selective Internal Radiation Therapy (SIRT)
Radiation Therapy Worksheet
(As of 09 June 2017)
6.
a. Has the patient been treated using SIRT in the past?
If no is selected, skip forward to question #7.
Yes No
b. If SIRT has been used in the past, how much time has passed since the last SIRT treatment?
45 or more days ago
less than 45 days ago
c. If SIRT was utilized 45 days or more ago, what was the outcome of the prior treatment?
The liver involvement is stable as a result of prior SIRT
The liver involvement decreased as a result of prior SIRT
There has been necrosis of the liver component with or without shrinkage as a result of prior SIRT
There has been improvement in liver function test results as a result of prior SIRT
There has been improvement in performance status or pain as a result of prior SIRT
None of the signs of improvement have occurred as a result of prior SIRT
7.
Is one or more of these conditions present?
Yes No
Ascites
Liver failure
Childs-Pugh status late B or C
Prior external beam radiation
to the liver
Prior extensive liver resection
Prior bilio-enteric anastomosis
Current or prior (within previous 2
months) capecitabine chemotherapy
Obstructed bile duct
Extensive portal vein thrombosis
Portal or biliary stent in place
8.
How many sessions/infusions of SIRT are being requested?
_____ sessions/infusions
9.
Note any additional information in the space below.
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Completed 23 June 2021

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