Radiation Therapy Physician Worksheet
(As of 17 July 2016)
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 start date (mm/dd/yyyy)?
Is this treatment being directed to the primary site?
If treatment is not being directed to the primary site, submit a request for the metastatic site.
Does the patient have distant metastatic disease?
a. What is the treatment intent?
Definitive (no surgery planned)
Locoregional recurrence at primary site or regional lymph nodes
Palliative (for relief of symptoms)
b. If preoperative or postoperative is the treatment intent, are any of the
following risk factors present?
1. Tumor > 4 cm
2. > 1 mm invasion
3. Lymphovascular invasion
4. Positive Pelvic Nodes
5. Positive Inguinal/Femoral Nodes
6. Positive/Close Surgical Margin (< 8 mm)
7. Pattern of invasion (spray, diffuse)
6. Positive inguinal/femoral nodes
c. If definitive is the treatment intent, what is the patient’s initial TNM (AJCC 7