Bone Metastases Radiation Therapy Physician Worksheet Pages 2-5. Brain Metastases Radiation Therapy Physician Worksheet Pages 6-9

Transcription

1 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 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: To initiate a telephonic request for a Radiation Therapy Treatment Plan, please dial: and follow the prompts to initiate a new radiation therapy treatment medical necessity determination request. Bone Metastases Radiation Therapy Physician Worksheet Pages 2-5 Brain Metastases Radiation Therapy Physician Worksheet Pages 6-9 Breast Cancer Radiation Therapy Physician Worksheet Pages Cervical Cancer Radiation Therapy Physician Worksheet Pages Primary Central Nervous System (CNS) Lymphoma Physician Worksheet Pages Primary Central Nervous System (CNS) Neoplasm Physician Worksheet Pages Colorectal Cancer Radiation Therapy Physician Worksheet Pages Endometrial Cancer Radiation Therapy Physician Worksheet Pages Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet Pages Head or Neck Radiation Therapy Physician Worksheet Pages Non-Cancerous Radiation Therapy Physician Worksheet Pages Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet Pages Other Cancer Type Radiation Therapy Physician Worksheet Pages Pancreatic Cancer Radiation Therapy Physician Worksheet Pages Prostate Cancer Radiation Therapy Physician Worksheet Pages Skin Cancer Radiation Therapy Physician Worksheet Pages Small Cell Lung Cancer Radiation Therapy Physician Worksheet Pages Radiation Oncology Procedure Code list Page 54

2 Bone 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

3 Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. What is the site of the primary cancer? Bladder Breast Cervical Colorectal Head/neck Kidney Lung Melanoma Pancreas Prostate Sarcoma Other: 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

4 Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) 5. 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) Intensity modulated radiation therapy (IMRT) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Proton beam therapy Proton beam therapy Proton beam therapy Rotational arc therapy Rotational arc therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT) Tomotherapy Tomotherapy Tomotherapy Fractions: Fractions: Fractions: Gantry angles: Gantry angles: Gantry angles: Please note that 3D technique is not considered medically necessary for standard two field treatment, and will not be reimbursed. 6. What is the reason for treatment? Select all that apply. Extension into viscera Palliation of pain Spinal cord compression Other: 7. Does the patient have visceral metastases (e.g. lung, liver, brain, adrenal, etc.)? Yes No Continued on next page

5 8. a. What is the patient s ECOG performance status? Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) 0 Fully active, able to carry on all pre-disease performance without restriction 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. Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. Capable of only limited self-care, confined to bed or chair more than 50% of waking hours. 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.

6 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

7 Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) Patient name: 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 *If yes, no further information is required. If no, please continue. 2. What is the primary site? Bladder Colorectal Lung Sarcoma Breast Head/Neck Melanoma Other: Gynecological Kidney Pancreas No 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. Restricted in physically strenuous activity but ambulatory and able to carry out 1 work of a light or sedentary nature, e.g., light house work, office work. Ambulatory and capable of all self-care but unable to carry out any work 2 activities. Up and about more than 50% of waking hours. Capable of only limited self-care, confined to bed or chair more than 50% of 3 waking hours. Completely disabled. Cannot carry on any self-care. Totally confined to bed or 4 chair. Continued on next page

8 Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) 7. a. Has the brain previously been treated with radiation therapy? Yes No b. If yes, what type of radiation therapy was previously used to treat the patient? Previous whole brain radiation therapy (WBRT) Previous stereotactic radiosurgery (SRS) 8. If previous WBRT was used to treat the patient, then answer the following questions: a. Was the last WBRT fraction delivered in the past 3 months? Yes No b. What is the date of the last WBRT treatment? / / 9. If SRS was previously used to treat the patient, then answer the following questions: a. Was the last SRS session delivered in the past 6 months? Yes No b. What is the date of the last SRS treatment? / / 10. How many active brain lesions are visible on the most recent MRI? or more 11. What is the treatment plan? Whole brain Partial brain 12. If whole brain is the selected treatment plan, then answer the following set of questions: a. What treatment technique will be used for WBRT? Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Tomotherapy b. How many whole brain fractions will be delivered? Fractions: c. Is a concurrent boost being delivered? If yes, answer questions corresponding to partial brain below. Yes No Continued on next page

9 Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015) 13. If partial brain is the selected treatment plan, then answer the following set of questions: a. Is only partial brain being treated (no WBRT)? Yes No b. Is this a boost in conjunction with WBRT? Yes No c. What is the treatment technique for the partial brain treatment? Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Proton beam therapy Intensity modulated radiation therapy (IMRT) Tomotherapy Stereotactic radiosurgery (SRS) d. How many partial brain fractions will be delivered? Fractions: Please note that 3D technique is not considered medically necessary for standard 2 field whole brain treatment, and will not be reimbursed. 14. Note any additional information in the space below.

10 Breast Cancer Radiation Therapy Physician Worksheet (As of 10 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

11 Breast Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) Patient name: 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 T2 T4 Ductal carcinoma T1 T3 Recurrent 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) Single fraction intra-operative radiotherapy (IORT) Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Tomotherapy Continued on next page

12 Breast Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) 8. What technique will be used for the boost phase of treatment? Electrons Photons Single catheter brachytherapy Electronic brachytherapy Multiple catheter brachytherapy Single fraction intra-operative radiotherapy (IORT) Accuboost No boost phase will be delivered 9. Will IGRT be used? Yes No 10. Will respiratory gating/deep inspiration breath hold (DIBH) be used for EBRT? Yes No 11. Note any additional information in the space below:

13 Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

14 Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) Patient name: What is the radiation therapy start date (mm/dd/yyyy)? / / 1. Is this treatment being directed to the primary site? 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? Yes No 3. a. What is the treatment intent? Post-operative Definitive Locoregional recurrence Palliative b. If post-operative is the treatment intent, are any of the following risk factors present? 1. Tumor > 4cm 2. Deep Stromal invasion 3. Lymphovascular invasion 4. Positive Pelvic Nodes 5. Positive Surgical Margin 6. Positive Parametrium c. If definitive is the treatment intent, what is the patient s initial FIGO (International Federation of Gynecology and Obstetrics) stage? Stage IA1 Stage IIA1 Stage IIIA Stage IA2 Stage IIA2 Stage IIIB Stage IB1 Stage IIB Stage IVA Stage IB2 Stage IVB Yes No 4. Will the para-aortic nodes be treated? Yes No 5. Is gross adenopathy present? Yes No 6. What is the treatment plan? External beam radiation therapy (EBRT) Brachytherapy Brachytherapy and EBRT Continued on next page

15 Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) 7. If brachytherapy is included in the treatment plan, then answer the following set of questions: a. What is the dose rate? Low dose rate (LDR) High dose rate (HDR) b. How many fractions will be rendered? Fractions: c. What is the implant type? Tandem only Vaginal cylinder only Tandem and ovoids Ovoids only Interstitial 8. If EBRT is included in the treatment plan, then answer the following set of questions: a. What EBRT technique will be used? Proton beam therapy Rotational arc therapy Tomotherapy Complex (77307) 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:

16 Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet (As of 10 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

17 Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet (As of 10 April 2015) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. a. Has the patient received chemotherapy? Yes No b. If the patient has received chemotherapy, what was the response? Complete response (CR) Partial response (PR) No response (NR) Progressive disease (POD) 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) Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Tomotherapy Number of fractions: 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Tomotherapy Number of fractions: 4. Will IGRT be used? Yes No 5. Note any additional information in the space below:

18 Primary Central Nervous System (CNS) Neoplasm 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: Member DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Physician Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: Facility 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: Check the appropriate box describing you: Ordering Physician Facility Other: Signature Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

19 Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet (As of 21 April 2015) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. What is the patient s WHO grade or diagnosis? WHO grade I: Pilocytic astrocytoma II: Low grade oligo/ astrocytoma/ependymoma III: Anaplastic astrocytoma IV: Glioblastoma multiform (GBM) Diagnosis Primary spinal tumor Ependymoma Recurrent primary CNS malignant tumor previously irradiated Adult medulloblastoma Supratentorial PNET (primitive neuroectodermal tumor) Benign: Meningioma, Schwannoma, Pituitary Adenoma Other: 2. What is the patient s ECOG performance status? 0 Fully active, able to carry on all pre-disease performance without restriction 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 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. Capable of only limited self-care, confined to bed or chair more than 50% of waking hours. 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

20 Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet (As of 21 April 2015) 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) Intensity modulated radiation therapy (IMRT) Tomotherapy Rotational arc therapy Proton therapy Stereotactic radiosurgery (SRS)/ Stereotactic body radiation therapy (SBRT) Number of fractions: 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Tomotherapy Rotational arc therapy Proton therapy Stereotactic radiosurgery (SRS)/ Stereotactic body radiation therapy (SBRT) Number of fractions: 5. Will the patient be receiving concurrent chemotherapy? Yes No 6. Will IGRT be used? Yes No 7. Note any additional information in the space below:

21 Signature Facility Physician Member Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

22 Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. Is the treatment being directed to the primary site (rectum)? Yes No If treatment is not being directed to the primary site, submit a request for the metastatic site. 2. What is the timing of radiation? Neo-adjuvant (pre-operative) Adjuvant radiation (post-operative) following local excision (e.g. transanal, Kraske) Adjuvant radiation (post-operative) following transabdominal resection (LAR or APR) Initial primary treatment/ definitive (no surgery planned) Local recurrence/ persistence 3. What is the clinical T stage? T0 T1 T2 T3 T4 4. What is the nodal status? Negative Positive N/A 5. a. Does the patient have metastatic disease? Yes No b. If the patient has metastatic disease, is he/she planned to undergo surgical resection of the metastases? 6. Were any of the following high risk features evident on the pathologic specimen? Lymphovascular space invasion Positive margins Poorly differentiated tumors No high risk features N/A Yes No Continued on next page 7. What is the treatment intent?

23 Definitive Palliation Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) 8. 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 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Tomotherapy Rotational arc therapy Proton beam therapy Number of fractions: 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Tomotherapy Rotational arc therapy Proton beam therapy Number of fractions: 9. Will the patient receive concurrent chemotherapy? Yes No 10. Will IGRT be used? Yes No 11. Note any additional information in the space below.

24 Signature Facility Physician Member Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

25 Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. Is this treatment being directed to the primary site? Yes No If treatment is not being directed to the primary site, submit a request for the metastatic site 2. What is the pathology? Endometrioid Papillary serous Clear cell Carcinosarcoma 3. Does the patient have distant metastatic disease? Yes No 4. What is the intent of treatment? Palliative Post-operative Definitive or medically inoperable Isolated locoregional recurrence after surgery 5. What is the FIGO (International Federation of Gynecology and Obstetrics) stage? Stage IA Stage IIA Stage IIIA Stage IVA Stage IIIC Stage IB Stage IIB Stage IIIB Stage IVB 6. What is the grade of the endometrial cancer? Grade 1 Grade 2 Grade 3 7. Are any of the following risk factors present? 1. Age is 60 years 2. Lymphovascular invasion 3. Lower uterine (cervical/glandular) involvement Yes No 8. Will the patient be receiving concurrent chemotherapy? Yes No Continued on next page

26 Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015) 9. What is the treatment plan? Brachytherapy External beam radiation therapy (EBRT) Brachytherapy and EBRT 10. If Brachytherapy is included in the treatment plan, then answer the following set of questions: a. What is the dose rate? Low dose rate (LDR) High dose rate (HDR) b. How many fractions will be rendered? Fractions: c. What is the implant type? Tandem only Vaginal cylinder only Ovoids only Tandem and ovoids Heyman capsules only Interstitial 11. If EBRT is included in the treatment plan, then answer the following set of questions: a. What EBRT technique will be used? Proton beam therapy Rotational arc therapy Tomotherapy Complex (77307) Intensity modulated radiation therapy (IMRT) Stereotactic body radiation therapy (SBRT) 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 12. Will IGRT be used? Yes No 13. Note any additional information in the space below:

27 Signature Facility Physician Member Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

28 Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. Will the treatment be directed to the primary site (stomach)? 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. a. What is the treatment intent? Pre-operative (neo-adjuvant) Post-operative (adjuvant) Definitive treatment Palliation b. If post-operative is the treatment intent, what is the pathological T stage? T1 T2 T3 T4 c. If post-operative is the treatment intent, what is the pathological N stage? N0 N1 d. If post-operative is the treatment intent, does the patient have any of the following risk factors? 1. Poor differentiation 2. Lymphovascular invasion 3. Perineural invastion 4. Age < 50 Yes No Continued on next page

29 Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) 4. a. What external beam radiation therapy (EBRT) technique will be used? 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Tomotherapy 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 5. Will the patient receive concurrent chemotherapy? Yes No 6. Will IGRT be used? Yes No 7. Note any additional information in the space below.

30 Signature Facility Physician Member Head or Neck 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

31 Head or Neck Radiation Therapy Physician Worksheet (As of 21 April 2015) Patient name: What is the radiation therapy start date (mm/dd/yyyy)? / / 1. Does the patient have distant metastatic disease (M1 stage)? Yes No If treatment is not being directed to the primary site, submit a request for the metastatic site. 2. What is the primary site? Lip and oral cavity Pharynx Larynx Nasal cavity and para-nasal sinuses Thyroid Mucosal melanoma of head and neck Occult/unknown primary Major salivary gland Other: 3. Please annotate the patient staging (use pathological staging if post-op): a. What is the clinical T stage? T0 T1 T2 b. What is the clinical N stage? N0 N1 N2a T3 T4 N2b N2c N3 4. What is the intent/timing of the treatment? Definitive Palliative Post-operative Isolated locoregional recurrence Pre-operative Salvage therapy 5. What technique will be used to deliver the radiation therapy? Brachytherapy External beam radiation therapy (EBRT) Continued on next page

32 Head or Neck Radiation Therapy Physician Worksheet (As of 21 April 2015) 6. If brachytherapy is the selected technique, then answer the following set of questions: a. What type of brachytherapy will be used? High dose rate Low dose rate b. What is the implant type? Interstitial Intracavitary 7. If EBRT is the selected technique, then what is the EBRT technique? Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs) Stereotactic body radiation therapy (SBRT) Intensity modulated radiation therapy (IMRT): fixed gantry Tomotherapy Rotational arc therapy Proton beam therapy 8. Will the patient be receiving concurrent chemotherapy? Yes No 9. Will the patient receive treatment twice daily during the course of treatment? Yes No 10. Note any additional information in the space below:

33 Signature Facility Physician Member Non Cancerous Radiation Therapy Physician Worksheet (As of 10 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

34 Non Cancerous Radiation Therapy Physician Worksheet (As of 10 April 2015) Patient name: 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? 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 Yes No 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.

35 Signature Facility Physician Member 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

36 Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 April 2015) Patient name: What is the radiation therapy treatment start date (mm/dd/yyyy)? / / 1. Is the treatment being directed to the primary site (lung)? Yes No If treatment is not being directed to the primary site, complete the worksheet that corresponds to the patient s diagnosis. 2. a. What is the clinical T-stage? TX T1 T2 T3 T4 Tis b. What is the clinical N-stage? NX N0 N1 N2 N3 c. What is the clinical M-stage? M0 M1 3. a. What is the treatment intent? Definitive Pre-operative (neo-adjuvant) Post- operative (adjuvant) Palliation b. If post-operative (adjuvant) is the treatment intent, then answer the following questions: i. What is the margin status? Negative Positive ii. Is there gross residual tumor? Yes No iii. Is there evidence of extracapsular extension? Yes No c. If palliation is the treatment intent, what technique will be used for palliation? External beam radiation therapy (EBRT) Brachytherapy If Brachytherapy will be used for palliation, skip forward to question #8. 4. What EBRT technique will be used to deliver the radiation therapy? Select a technique for each applicable phase, and fill in the number of fractions. Continued on next page

37 Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 April 2015) Phase 1 Phase 2 Phase 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) Intensity modulated Intensity modulated Intensity modulated radiation therapy radiation therapy (IMRT) radiation therapy (IMRT) (IMRT) Proton beam therapy Proton beam therapy Proton beam therapy Rotational arc therapy Rotational arc therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT) Tomotherapy Tomotherapy Tomotherapy Number of fractions: Number of fractions: Number of fractions: 5. Will respiratory motion management be utilized? Yes No 6. Will concurrent chemotherapy be performed? Yes No 7. Will IGRT be used? Yes No 8. If brachytherapy will be utilized for palliation, then answer the following questions: a. Has the patient received EBRT? Yes No b. How many brachytherapy treatments (fractions) will be Fractions: utilized? c. How many brachytherapy applications will be utilized? Applications: 9. Note any additional information in the space below.

38 Signature Facility Physician Member 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other

39 Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 April 2015) Patient name: 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 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. Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours. Capable of only limited self-care, confined to bed or chair more than 50% of waking hours. 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? 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 Yes 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? b. Nodes: T1 T2 T3 T4 Tx Tis N0 N1 N2 N3 NX 6. Has this area received previous radiation? Yes No 7. Will the patient receive concurrent chemotherapy? Yes No No Continued on next page

40 8. a. What is the treatment plan? Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 April 2015) External beam radiation therapy (EBRT) Brachytherapy Brachytherapy and EBRT Selective internal radiation therapy (SIRT) Iodine-131 (I-131) b. If SIRT is the selected treatment plan, how many treatments will be used? Treatments: If Selective internal radiation therapy (SIRT) or Iodine-131 (I-131) is the selected treatment plan, skip forward to question #11. Otherwise, continue forward to question #9 9. If EBRT is included in the treatment plan, then answer the following set of questions: a. Will IGRT be used? Yes No b. What is the EBRT technique? Select a technique for each applicable phase, and fill in the number of fractions Phase 1 Phase II Phase III 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) Electrons Electrons Electrons Intensity modulated radiation therapy (IMRT) Intensity modulated radiation therapy (IMRT) Intensity modulated radiation therapy (IMRT) Proton beam therapy Proton beam therapy Proton beam therapy Rotational arc therapy Rotational arc therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT)/Stereotactic radiosurgery (SRS) Stereotactic body radiation therapy (SBRT)/Stereotactic radiosurgery (SRS) Stereotactic body radiation therapy (SBRT)/Stereotactic radiosurgery (SRS) Tomotherapy Tomotherapy Tomotherapy Number of fractions: Number of fractions: Number of fractions: Continued on next page

41 Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 April 2015) 10. If brachytherapy is included in the treatment plan, then answer the following set of questions: a. What is the dose rate? Low dose rate (LDR) High dose rate (HDR) b. How many applications will be used? Applications: 11. Note any additional information in the space below:

42 Signature Facility Physician Member Pancreatic Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014) 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 Fax form (non-urgent requests only) to Patient First Name: Patient Last Name: DOB: Member ID: Group #: Health Plan: Physician First Name: Physician Last Name: Primary Specialty: NPI: Tax ID: Phone #: Fax #: Contact Facility Name: Facility Tax ID: 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: Check the appropriate box describing you: Ordering Physician Facility Other: Sign and Date Below: Print Name: Sign Name: MD RN LPN PA NP Other