Soft Tissue Sarcoma
Radiation Therapy Worksheet
(As of 19 January 2018)
This worksheet is to be used for curative or palliative treatment of soft tissue sarcoma. If the treatment is for metastases
from soft tissue sarcoma, 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.
What is the radiation therapy treatment start date (mm/dd/yyyy)?
Where is the soft tissue sarcoma located?
What is the intent of treatment?
Palliative, for relief of symptoms
Definitive, biopsy only and no resection completed or planned
Pre-operative, resection planned after pre-operative radiation
Borderline resectable, neoadjuvant radiation to convert from unresectable to resectable
Post-operative, resection performed no pre-radiation given
Post-operative, pre-operative radiation was given
Re-treatment of localized recurrent disease with curative, salvage intent
c. Does the patient have distant metastases (stage M1) (i.e. to brain, lung,