Download Brachytherapy for Oncologic Indications

REVIEW REQUEST FOR
Brachytherapy for Oncologic Indications
Provider Data Collection Tool Based on Federal Employee Medical Policies 8.01.13 (Breast CA), 8.01.14 (Prostate);
8.03.11 (Lung Cancer) and historic Anthem Corporate Medical Policy RAD.00014 (All Oncologic Use) Archived as of
1/13/2010 so not used for prospective reviews
Policy Last Review
09/08/2011; 12/07/2011
Date:
12/7/2011;
Policy Effective Date: 01/01/2012; 10/01/2011;
01/01/2012
Provider Tool Effective Date: 03/07/2012
Member Name:
Date of Birth:
Insurance Identification Number:
Member 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 (ICD-9) if known):
Please check all that apply to the individual:
Breast Cancer:
Request s for high dose rate electronic brachytherapy
Request is for Breast brachytherapy as an adjunctive “boost” to the tumor bed for a member who has received whole breast
radiation therapy after prior breast conserving surgery (i.e., lumpectomy).
Request is for Breast brachytherapy as a technique of partial breast irradiation (e.g., multicatheter interstitial; Mammosite
RTS device, Proxima Therapeutics, Alpharetta, GA) as an alternative to whole breast irradiation (check all that apply):
Tumor removed with breast conserving surgery (i.e., 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: _______________
Prostate Cancer:
Request is for high dose electronic brachytherapy
Individual has Prostate cancer (check all that apply):
Request is for permanent radioactive seed implantation for prostate cancer with or without EBRT
Request is for high dose rate (HDR) brachytherapy, a temporary seed implantation, for clinically localized prostate
cancer that is T2b to T2c with a Gleason score 7 or less and a PSA value 10-20ng/mL
Other:
Endobronchial Tumors:
Request is for high dose 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
Other:
HISTORIC DIAGNOSES
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 margins (R1)
Resected gross residual disease (R2)
Carcinoma in situ at margins
Positive regional nodes
Other: _______________
Esophageal Cancer:
Request is for high dose 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 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:
Ocular Brachytherapy:
Request is for high dose electronic brachytherapy
Request is for Ocular brachytherapy for choroidal melanoma and retinoblastoma (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:
Penile Cancer:
Request is for high dose electronic brachytherapy
Request is brachytherapy for Penile cancer (check all that apply):
Squamous cell carcinoma confined to the glans or prepuce
Tumor size is less than or equal to 4cm
Inguinal lymph nodes are negative (N0) or are unable to be assessed (NX)
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Other:
Soft Tissue Sarcoma:
Request is for high dose electronic brachytherapy
Request is for brachytherapy as part of combination therapy in a member with soft tissue sarcoma that (check all that
apply):
Has positive margins
Has margins < 5mm
Other:
Uterine, Cervical, Endometrial and Vulvar/Vaginal Cancer:
Request is for high dose electronic brachytherapy
Request is for brachytherapy in 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 Anthem 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
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