Fillable Testicular Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Testicular Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Testicular Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
This worksheet is to be used for curative or palliative treatment of testicular cancer. If the treatment is for metastases from
testicular 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.
First Name:
Middle Initial:
Last Name:
DOB (mm/dd/yyyy):
Member ID:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
_____ /_____ /______
1.
What is the primary histology?
Seminoma
2.
Does the patient have distant metastases (stage M1) (i.e. to brain, lung,
liver, bone)?
Yes No
3.
What is the treatment intent?
Postoperative (adjuvant)
4.
What is the clinical stage?
Stage I (IA or IB or IS)
Stage IIA or IIB
Stage IIC
Stage III (IIIA – IIIC)
Continued on next page
Testicular Cancer
Radiation Therapy Physician Worksheet
(As of 14 April 2017)
5.
What is the treatment plan?
Phase I Phase II (if applicable)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct / 3D
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy (IMRT)
Tomotherapy Direct / 3D
Rotational arc therapy
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
Number of fractions: ______ Number of fractions: ______
6. Is the area to be treated abutting or overlapping a previously irradiated
area?
Yes No
7.
Will daily image-guided radiation therapy (IGRT) be used?
Yes No
8. Note any additional information in the space below.
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Testicular Cancer Radiation Therapy Physician Worksheet (As of (eviCore)

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Completed 23 June 2021

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