Download Brachytherapy

REVIEW REQUEST FOR
Brachytherapy for Oncologic Indications
Provider Data Collection Tool Based on Coverage Guideline RAD.00014
Policy Last Review Date: 05/07/2015
Policy Effective Date:
07/07/2015
Provider Tool Effective Date: 07/07/2015
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
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:
Service Requested (CPT if known):
Place of Service:
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please check all that apply to the individual:
Central Nervous System Tumors:
Request is for brachytherapy for intracavitary treatment of CNS tumor
Other:
Breast Cancer:
Request is for high dose rate electronic brachytherapy
Request is for breast brachytherapy as an adjunctive “boost” to the tumor bed for an individual who has received whole
breast radiation therapy after prior breast conserving surgery (for example, lumpectomy).
Request is for breast brachytherapy as a technique of partial breast irradiation (for example, multicatheter interstitial or
balloon) as an alternative to whole breast irradiation (check all that apply):
Tumor removed with breast conserving surgery (for example, lumpectomy) with resected margins free of tumor;
Stage 0, I, or II disease (Stage II tumors must be less than or equal to 3cm in diameter);
Node negative
Individual’s age is greater than or equal to 50 years
Other:
Cholangiocarcinoma:
Request is for high dose rate electronic brachytherapy
Request is for brachytherapy as a secondary or adjuvant treatment for an individual with cholangiocarcinoma
(check all that apply):
Resected with positive margin (R1)
Resected gross residual disease (R2)
Carcinoma in situ at margin
Postive regional nodes
Other:
Ocular Brachytherapy:
Request is for high dose rate electronic brachytherapy
Request is for Ocular brachytherapy for choroidal melanoma (check all that apply):
Unilateral choroidal melanoma has been confirmed
Apical height of the tumor is 2.5 to 10.0mm
Maximum basal tumor diameter of 18.0mm or less
Other:
Request is for Ocular brachytherapy for retinoblastoma: (check all that apply)
Apical height of the tumor is 2.5 to 10.0mm
Maximum basal tumor diameter of 18.0mm or less
Other:
Endobronchial Tumors:
Request is for high dose rate electronic brachytherapy
Request is for Endobronchial brachytherapy (check all that apply):
Primary tumor cannot be excised
Primary tumor cannot be treated by external beam radiation therapy (EBRT)
As a palliative treatment for obstructing primary or metastatic endobronchial tumors
As a “boost” for EBRT
Other:
Esophageal Cancer:
Request is for high dose rate electronic brachytherapy
Request is for Esophageal brachytherapy (check all that apply):
Unresectable tumor(s)
Palliative treatment for obstructing tumors
Other:
Head and Neck Cancers:
Request is for high dose rate electronic brachytherapy
Request is for brachytherapy for the treatment of head and neck cancer(s) (check all that apply)
lip
tongue
floor of mouth
tonsil
pharynx
nasopharynx,
sinuses
neck cancers
Other:
Penile Cancer:
Request is for high dose rate electronic brachytherapy
Request is for brachytherapy for an individual with penile cancer: (check all that apply)
Squamous cell carcinoma is confined to the glans or prepuce
Tumor size is less than or equal to 4 cm
Inguinal lymph nodes are negative (N0) or unable to be assessed (NX)
Other:
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Prostate Cancer:
Request is for high dose rate electronic brachytherapy
Individual has prostate cancer that is clinically localized (check all that apply):
Individual with low-risk of recurrence (tumor stage T1-T2a, low Gleason score ([GS] less than or equal to 6),
serum prostate specific antigen (PSA) level below 10ng/mL and greater than or equal to 10 year expected survival
Treatment will involve permanent low dose rate (LDR) brachytherapy as monotherapy
Individual with intermediate-risk of recurrence (tumor stage any T2b to T2c, or GS of 7, or
PSA value of 10-20 ng/mL) (Check 1 of the following that applies)
Treatment will involve LDR brachytherapy with or without EBRT
Treatment will involve HDR brachytherapy with or without EBRT
Individual with high-risk of recurrence (stage T3a or Gleason score[GS] 8-10) or
PSA level greater than 20 ng/mL (Check 1 of the following that applies)
Treatment will involve LDR brachytherapy in combination with EBRT
Treatment will involve HDR brachytherapy in combination with EBRT
Other:
Soft Tissue Sarcoma:
Request is for high dose rate electronic brachytherapy
Request is for brachytherapy as part of combination therapy in an individual with soft tissue sarcoma that
(check all that apply):
Has positive margins
Has margins less than 5mm
Other:
Gynecologic Cancers:
Request is for high dose rate electronic brachytherapy
Request is for brachytherapy in an individual diagnosed with uterine, cervical, endometrial or vulvar/vaginal cancer
Other:
This request is being submitted:
Pre-Claim
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that the health plan or its
designees may perform a routine audit and request the 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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