Radiation Therapy Breast Cancer Request
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.
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Patient/
Member
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyyy):
Gender: Male Female
Health Plan: Member ID:
Clinical Information
ICD-10 Code(s):
What is the radiation therapy treatment start date (mm/dd/yyyy)?
eviCore is utilizing a clinical decision support submission model for this diagnosis.
Please note that only some of the following example questions will need to be answered during the
submission of your prior authorization request.
For best results, the answers to these questions should be submitted online.
What is the treatment plan?
Whole breast radiation without regional nodal radiation
Partial breast irradiation (PBI) without regional nodal radiation
Whole breast radiation with regional nodal radiation (i.e., axillary, supraclavicular, and/or internal
mammary nodes)
Treatment of bilateral breast cancer
Post-mastectomy radiation therapy (PMRT)
Accelerated partial breast irradiation (APBI)
Intraoperative radiation therapy (IORT)
Radiation to the breast or chest wall with or without regional nodal radiation in a patient with local
recurrence only and no distant metastatic disease
Radiation to the breast or chest wall with or without regional nodal radiation in a patient with a history of
distant metastatic disease (e.g. to the brain, lung, liver, and/or bone)
Re-irradiation of the breast or chest wall with or without regional nodal radiation
Palliative radiation therapy to the breast or chest wall with or without regional nodal radiation
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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
Clinical Information
What treatment technique will be used for the initial phase?
Conventional isodose planning, complex
Electron Beam Therapy
3D conformal
Tomotherapy Direct/3D
Intensity Modulated Radiation Therapy (IMRT)
Tomotherapy (IMRT)
Rotational Arc Therapy
Proton Beam Therapy
Stereotactic Body Radiation Therapy (SBRT) (using photons)
Stereotactic Body Radiation Therapy (SBRT) (using protons)
Low Dose Rate (LDR) Brachytherapy
High Dose Rate (HDR) Brachytherapy
AccuBoost
Electronic Brachytherapy (HDR)
Electron Beam IORT (i.e. Mobetron)
Low-Energy X-Ray IORT (i.e. IntraBeam)
Electronic Brachytherapy IORT (i.e. Xoft or Axxent)
How many fractions will be used for the initial phase?
Will image guided radiation therapy (IGRT) be used for the initial phase? Yes No N/A
Will respiratory motion tracking be used for the initial phase? Yes No N/A
How will the patient be treated for the initial phase? Supine Prone N/A
What treatment technique will be used for the boost phase?
Intensity Modulated Radiation Therapy (IMRT)
Tomotherapy (IMRT)
Rotational Arc Therapy
Proton Beam Therapy
Stereotactic Body Radiation Therapy (SBRT) (using photons)
Stereotactic Body Radiation Therapy (SBRT) (using protons)
Electrons
Photons
High Dose Rate (HDR) Brachytherapy
AccuBoost
Electronic Brachytherapy (HDR)
N/A
How many fractions will be used for the boost phase?
Will image guided radiation therapy (IGRT) be used for the boost phase? Yes No N/A
Which breast will be treated? Bilateral Left Right N/A
Will treatment include the supraclavicular nodes? Yes No N/A
Will treatment include the internal mammary nodes? Yes No N/A
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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
Clinical Information
For APBI or IORT, what is the stage?
T1mi N0
T1a N0
T1b N0
T1c N0
T2 N0
T3 N0
T4a N0
T4b N0
T4c N0
T4d N0
Ductal Carcinoma In Situ (DCIS)
Other: ___________
For APBI or IORT, Does the patient meet any of the following “Suitable” criteria (as defined in the ASTRO
consensus statement for APBI and by NCCN
®
)?
Invasive Tumors - Patient is BRCA-negative; Tumor is ER-positive with negative margins of at least 2
mm and without lymphovascular invasion (LVI)
In Situ Tumors - Tumor was detected by screening, is low or intermediate grade, is ≤2.5 cm and has
negative margins of at least 3 mm
None of the above
Please be prepared to submit consult note, results of imaging from the past 60 days and radiation
prescription or clinical treatment plan in order to expedite the review process. Failure to provide all
relevant information may result in a delay in case processing.
Additional Comments/Information: