Radiation Therapy Non-Small Cell Lung 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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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
Patient/
Member
First Name: Middle Initial: Last Name:
DOB (mm/dd/yyy):
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 stage of the lung cancer at the time of original diagnosis?
IA or IB
IIA (T2bN0)
IIB (T3N0)
IIB (T1N1, T2N1)
IIIA
IIIB
IIIC
IV (including oligometastatic disease)
Loco-regional Recurrence
What is the treatment intent?
Curative, No surgery planned or performed
Curative, Post-operative (adjuvant)
Curative, Pre-operative (neo-adjuvant)
Curative, Treatment of the primary in an oligometastatic setting
Palliative (to alleviate symptoms)
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eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd ● Bluffton, SC ● 29910 | 800.918.8924
Clinical Information
How many fractions will be used for each phase?
Phase 1 Phase 2 Phase 3 Treatment Technique
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 and 3D
planning)
Stereotactic Body Radiation Therapy (SBRT) (using photons and IMRT
planning)
Stereotactic Body Radiation Therapy (SBRT) (using protons and 3D
planning)
Stereotactic Body Radiation Therapy (SBRT) (using protons and IMRT
planning)
High Dose Rate (HDR) Brachytherapy
N/A
Will image guided radiation therapy (IGRT) be used for treatment? Yes No N/A
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.
Additional Comments/Information: