Download External Beam Intraoperative Radiation Therapy

REVIEW REQUEST FOR
External Beam Intraoperative Radiation Therapy
Provider Data Collection Tool Based on Medical Policy THER-RAD.00004
Policy Last Review Date: 11/03/2016
Policy Effective Date:
12/28/2016
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
12/28/2016
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
This medical policy based data collection tool is for a medical necessity review request for the delivery of external beam
radiation therapy during surgery. External beam intraoperative radiation therapy (IORT) is a technique involving radiation
treatment (radiotherapy) delivered to the tumor bed, regional lymph nodes, or both during a surgical procedure.
Note: The delivery of intraoperative brachytherapy as a form of radiation therapy is addressed separately in the following
document:
THER-RAD.00001 Brachytherapy for Oncologic Indications
Please check all that apply to the individual:
Request is for external beam intraoperative radiation therapy (IORT)
IORT is being used as the sole source of boost therapy at the time of surgical excision for: (Check all that apply)
Colorectal cancer
Pancreatic cancer
Pelvic cancers (for example, cervical or uterine)
Soft tissue sarcomas
Breast cancer
Other (Please list)
Tumor cannot be completely removed
Tumor has a high risk of recurring in surrounding tissues
Other (Please list)
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REVIEW REQUEST FOR
External Beam Intraoperative Radiation Therapy
Provider Data Collection Tool Based on Medical Policy THER-RAD.00004
Policy Last Review Date: 11/03/2016
Policy Effective Date:
12/28/2016
Provider Tool Effective Date:
12/28/2016
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I confirm that the information entered on this form is accurate and complete based on the records available at the time of this
request. I understand the health plan or its designees may request medical documentation to verify the accuracy of the
information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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