Small Cell Lung Cancer
Radiation Therapy Physician Worksheet
(As of 19 January 2018)
This worksheet is to be used for curative or palliative treatment of primary small cell lung cancer. If the treatment is for PCI
(Prophylactic Cranial Irradiation), then please use the appropriate PCI worksheet. If the treatment is for metastases from
lung 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
What is the radiation therapy treatment start date (mm/dd/yyyy)?
What is the stage of the cancer?
If extensive stage, what is the response following chemotherapy?
No response (NR)
Partial response (PR)
Progressive disease (POD)
a. What is the clinical T-stage?
b. What is the clinical N-stage?
c. Does the patient have distant metastases (stage M1) (i.e. to brain, lung, liver, bone)?
a. What is the treatment intent?
Palliative (for relief of symptoms)