Fillable Small Cell Lung Cancer Radiation Therapy Physician Worksheet (eviCore)

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Small Cell Lung Cancer Radiation Therapy Physician Worksheet (eviCore)

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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
by phone.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ / _____ / ______
1.
What is the stage of the cancer?
Limited Extensive
2.
If extensive stage, what is the response following chemotherapy?
Complete response (CR)
No response (NR)
Partial response (PR)
Progressive disease (POD)
3.
a. What is the clinical T-stage?
TX T1 T2 T3 T4
b. What is the clinical N-stage?
NX N0 N1 N2 N3
c. Does the patient have distant metastases (stage M1) (i.e. to brain, lung, liver, bone)?
Yes No
4.
a. What is the treatment intent?
Definitive (curative)
Palliative (for relief of symptoms)
Continued on next page
Small Cell Lung Cancer
Radiation Therapy Physician Worksheet
(As of 19 January 2018)
5.
What is the treatment plan?
Phase 2 (if applicable)
Phase 3 (if applicable)
Complex (77307)
Complex (77307)
3D conformal
3D conformal
Intensity Modulated
Radiation Therapy (IMRT)
Intensity Modulated
Radiation Therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct/3D
Tomotherapy Direct/3D
Rotational arc therapy
Rotational arc therapy
Stereotactic body
radiation therapy (SBRT)
Stereotactic body radiation
therapy (SBRT)
Proton beam therapy
Proton beam therapy
Number of fractions: ______
Number of fractions: ______
6.
Will the patient be receiving concurrent chemotherapy?
Yes No
7.
Is the area to be treated abutting or overlapping a previously irradiated
area?
Yes No
8.
Will respiratory motion management be used?
Yes No
9.
Will hyper-fractionation (BID) be used?
Yes No
10.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
11.
Note any additional information in the space below:
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Small Cell Lung Cancer Radiation Therapy Physician Worksheet (eviCore)

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Completed 23 June 2021

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