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: 05/04/2017
Policy Effective Date:
05/18/2017
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
05/18/2017
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), performed with either electron
beams (IOERT) or photon beams, 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 as the sole source of additional radiotherapy
at the time of surgical excision for: (If checked, mark all of the following that that apply to the individual)
Colorectal cancer
Pancreatic cancer
Pelvic cancers (for example, cervical or uterine)
Soft tissue sarcomas
Breast cancer
Other (Please list)
Tumor cannot be completely removed with excision
Tumor has a high risk of recurring in surrounding tissues
Intraoperative radiation therapy will augment conventional external beam radiation therapy
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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: 05/04/2017
Policy Effective Date:
05/18/2017
Provider Tool Effective Date:
05/18/2017
Other (Please list)
Request is for external beam intraoperative partial breast irradiation (electron or low-energy x-ray radiotherapy) as an
alternative to whole breast irradiation in the treatment of early stage breast cancer
(If checked, mark the following that apply to the individual)
Individual is 50 years of age or older
Individual is clinically node negative on preoperative physical examination (that is, non-palpable node[s]),
Individual is clinically node negative on medical imaging, if performed (for example, mammography,
magnetic resonance imaging [MRI], or ultrasound)
Tumor is invasive ductal carcinoma measuring less than or equal to 2 centimeters (T1 disease) with
negative margin widths of greater than or equal to 2 millimeters
(If checked, mark the following that apply to the individual)
There is NO lymphovascular space invasion
The tumor is estrogen-receptor positive (ER+)
Individual is BRCA gene negative
Tumor is low or intermediate nuclear grade, screen-detected ductal carcinoma in situ measuring less than
or equal to 2.5 centimeters with negative margin widths of greater than or equal to 3 millimeters.
______________________________________________________________________________________________________
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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