eviCore Healthcare needs to collect sufficient clinical history and treatment plan informaon relevant to a request for radiaon therapy treatment to establish the medical necessity of the service. eviCore Healthcare has provided a packet of cancer specific worksheets that will help you organize the informaon necessary to complete a medical necessity review of a radiaon therapy treatment plan. The worksheets will guide you in preparing the specific informaon that will be collected on the phone or through the website submission portal. These worksheets can be faxed to 615.468.4457 to ensure proper medical necessity determinaon. The most efficient way for a physician to obtain a medical necessity determinaon is to iniate a web request for a Radiaon Therapy Treatment Plan by vising the Medsoluons website: hps://myportal.medsoluons.com To iniate a telephonic request for a Radiaon Therapy Treatment Plan, please dial: 888.693.3211 and follow the prompts to iniate a new radiaon therapy treatment medical necessity determinaon request. Bone Metastases Radiaon Therapy Physician Worksheet Pages 2 - 5 Brain Metastases Radiaon Therapy Physician Worksheet Pages 6 - 9 Breast Cancer Radiaon Therapy Physician Worksheet Pages 10 - 12 Cervical Cancer Radiaon Therapy Physician Worksheet Pages 13 - 15 Primary Central Nervous System (CNS) Lymphoma Physician Worksheet Pages 16 - 17 Primary Central Nervous System (CNS) Neoplasm Physician Worksheet Pages 18 - 20 Colorectal Cancer Radiaon Therapy Physician Worksheet Pages 21 - 23 Endometrial Cancer Radiaon Therapy Physician Worksheet Pages 24 - 26 Gastric (Stomach) Cancer Radiaon Therapy Physician Worksheet Pages 27 - 29 Head or Neck Radiaon Therapy Physician Worksheet Pages 30 - 32 Non-Cancerous Radiaon Therapy Physician Worksheet Pages 33 - 34 Non-Small Cell Lung Cancer Radiaon Therapy Physician Worksheet Pages 35 - 37 Other Cancer Type Radiaon Therapy Physician Worksheet Pages 38 - 41 Pancreac Cancer Radiaon Therapy Physician Worksheet Pages 42 - 43 Prostate Cancer Radiaon Therapy Physician Worksheet Pages 44 - 47 Skin Cancer Radiaon Therapy Physician Worksheet Pages 48 - 50 Small Cell Lung Cancer Radiaon Therapy Physician Worksheet Pages 51 – 53 Radiaon Oncology Procedure Code list Page 54
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Bone Metastases Radiation Therapy Physician … Metastases Radiation Therapy Physician Worksheet Pages 2 - 5 ... Other Cancer Type Radiation Therapy Physician Worksheet ... Patient
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eviCore Healthcare needs to collect sufficient clinical history and treatment plan information relevant to a request for radiation therapy treatment to establish the medical necessity of the service. eviCore Healthcare has provided a packet of cancer specific worksheets that will help you organize the information necessary to complete a medical necessity review of a radiation therapy treatment plan. The worksheets will guide you in preparing the specific information that will be collected on the phone or through the website submission portal. These worksheets can be faxed to 615.468.4457 to ensure proper medical necessity determination.
The most efficient way for a physician to obtain a medical necessity determination is to initiate a web request for a Radiation Therapy Treatment Plan by visiting the Medsolutions website: https://myportal.medsolutions.com To initiate a telephonic request for a Radiation Therapy Treatment Plan, please dial: 888.693.3211 and follow the prompts to initiate a new radiation therapy treatment medical necessity determination request.
Bone Metastases Radiation Therapy Physician Worksheet Pages 2 - 5
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)
2. Is this a solitary bone metastasis? Yes No 3. What is the location of the metastasis?
Femur Humerus Pelvis Rib
Shoulder Skull Spine - levels to be treated : _______ Other: _________________________
4. a. Are you treating a second and/or third bone site for this patient? Yes No
b. If a second and/or third site is being treated, what is the location of the metastasis? Select the location of the metastasis for each additional site being treated.
Site 2 Site 3
Femur Humerus Pelvis Rib Shoulder Skull Spine - levels to be treated : _______ Other: _________________________
Femur Humerus Pelvis Rib Shoulder Skull Spine - levels to be treated : _______ Other: _________________________
c. Will the sites be treated concurrently? Yes No
Continued on next page
Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)
What is the external beam radiation therapy (EBRT) treatment technique? Select the treatment technique for each site, and fill in the number of gantry angles and fractions.
Site 1 Site 2 Site 3
Complex (77307) Complex (77307) Complex (77307)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
8. a. What is the patient’s ECOG performance status?
0 Fully active, able to carry on all pre-disease performance without restriction.
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
b. If ECOG performance status is 3 or 4, is it expected that the ECOG status will improve as a result of this treatment? Yes No
9. Is the area to be treated abutting, overlapping, or within a previously
irradiated area? Yes No
10. Will IGRT be used? Yes No 11. Note any additional information in the space below.
Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)
What is the radiation therapy treatment start date (mm/dd/yyyy)? ______ /______ /______ 1. Is whole brain radiation therapy (WBRT) with complex (77307) technique
and a maximum of 10 fractions being requested*? Yes No
*If yes, no further information is required. If no, please continue. 2. What is the primary site?
Bladder Breast Gynecological
Colorectal Head/Neck Kidney
Lung Melanoma Pancreas
Sarcoma Other: __________
3. Is the primary tumor controlled? Yes No
4. Are non-brain visceral metastases (e.g. lung, liver, etc.) present on the most recent radiologic studies?
Yes No
5. a. Is the patient receiving chemotherapy or other systemic treatment? Yes No
b. If no, why is the patient not receiving chemotherapy or other systemic treatment?
The non-brain metastatic disease is stable; and therefore, not requiring systemic therapy There are no good systemic treatment options The patient is refusing systemic therapy The patient’s performance status does not allow for the delivery of systemic therapy
6. What is the patient’s
ECOG performance status?
0 Fully active, able to carry on all pre-disease performance without restriction.
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
Continued on next page
Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Breast Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)
What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /______ /______ 1. Is the treatment being directed to the primary site (breast)? Yes No
If treatment is not being directed to the primary site, submit a request for the metastatic site
2. Does the patient have distant metastatic disease (M1 stage)? Yes No 3. Are you delivering adjuvant therapy to the whole breast or chest wall using
two gantry angles and 3D conformal treatment planning? If no, continue to question #4. If yes, skip forward to question #8.
Yes No
Please note that AMA and ASTRO position is that forward planned IMRT is billed as 3D conformal
4. What is the T-stage (pathologic T-stage if patient has had surgery)?
T0 T1
T2 T3
T4 Recurrent
Ductal carcinoma In Situ (DCIS)
5. What treatment plan to be executed for the initial phase?
Whole breast or chest wall radiotherapy (mastectomy performed) Partial breast radiotherapy once a day Partial breast radiotherapy twice a day
6. Will treatment include the internal mammary nodes? Yes No 7. What technique will be used for the initial phase of treatment?
Single catheter brachytherapy Multiple catheter brachytherapy Electronic brachytherapy Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)
Stereotactic body radiation therapy (SBRT) Intensity modulated radiation therapy (IMRT) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,
conformal beams, DVHs, DRRs)
b. How many fractions will be rendered in phase 1? Fractions: _____
c. If applicable, how many fractions will be rendered in phase 2? Fractions: _____ N/A
9. Will the patient be receiving concurrent chemotherapy? Yes No
10. Will IGRT be used? Yes No
11. Note any additional information in the space below:
Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet
2. Will the patient be receiving concurrent chemotherapy? Yes No 3. What external beam radiation therapy (EBRT) technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1 Phase 2
Complex (77307) Complex (77307)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section. URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
3. What resection has been performed?
Biopsy only Subtotal resection Gross total resection
Continued on next page
Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet
4. What external beam radiation therapy technique will be used to deliver the radiation therapy? Select a technique for each applicable phase, and fill in the number of fractions.
Phase I Phase II
Complex (77307) Complex (77307)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /______
1. Is the patient receiving radiation therapy for a benign tumor or other
non-cancerous diagnosis? Yes No
If treatment is not being received for a benign tumor or other non-cancerous diagnosis, then complete the “Cancer Other” worksheet or the worksheet that corresponds to the patient’s diagnosis
2. a. Why is the patient receiving radiation therapy?
Acoustic neuroma
Arteriovenous malformation (AVM)
Benign tumor
Cavernous Malformations
Epilepsy
Graves ophthalmopathy
Keloid scar
Parkinson’s disease
Pre/post orthopedic surgery
Prevention of calcifications
Trigeminal neuralgia
Other: _________________
b. If “other” was the selected reason, please explain the “other” reason for treatment below:
3. a. What external beam radiation therapy (EBRT) technique will be used?
Tomotherapy
Rotational arc therapy
Proton beam therapy
Electrons
Complex (77307)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,
conformal beams, DVHs, DRRs)
Stereotactic radiosurgery (SRS)/
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT
b. How many fractions will be rendered in phase 1? Fractions: _____
c. If applicable, how many fractions will be rendered in phase 2? Fractions: _____ N/A
4. Will IGRT be used? Yes No
5. Note any additional information in the space below.
Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 April 2015)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /_______
1. What is the primary site (fill in blank)? ______________________________
2. a. What is the
patient’s
ECOG
performance
status?
0 Fully active, able to carry on all pre-disease performance without restriction.
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.
b. If the ECOG status is due to the cancer, is the status expected to
improve with radiation therapy treatment? Yes No
3. Does the patient have distant metastatic disease? Yes No
If the diagnosis is brain or bone metastases, stop and use the brain or bone metastases worksheet
4. a. What is the intent of treatment?
Initial primary treatment
Pre-operative radiation
Post-operative radiation
Palliation at primary site
Isolated local recurrence at primary or adjacent site
Palliation of metastatic site - explain below in question #4b
Other - explain below in question #4b
b. If intent of treatment is “palliation of metastatic site” or “other”, then use the space below to list the
metastatic sites to be treated and to explain the treatment intent in further detail.
If treatment intent is “palliation at metastatic site”, “palliation at primary site” or “other” (see question
#4a), skip forward to question #8. Otherwise, continue forward to question #5
5. a. What is the clinical stage?
T1 T2 T3 T4 Tx Tis
b. Nodes:
N0 N1 N2 N3 NX
6. Has this area received previous radiation? Yes No
7. Will the patient receive concurrent chemotherapy? Yes No
Continued on next page
Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 April 2015)
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with
regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.
URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: NPI: RETRO Date of Service:
Who will be the responsible contact for additional information, if requested, or question concerning this request?
Please select the appropriate CPT code and include the number of units that are being requested. If your code is not listed, please provide the CPT and number of units in the blank spaces at the bottom of the form.