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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: 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) Page 1 of 2 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. Page 2 of 2