Download Intensity Modulated Radiation Therapy

REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Coverage Guideline RAD.00041
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:
Request is for Intensity Modulated Radiation Therapy (IMRT) for: (check all that apply)
Prostate cancer
Localized prostate cancer
Post-prostatectomy for dose escalation greater than or equal to 64 Gy (check all that apply)
PSA remains detectable at 6 months after surgery
PSA is detectable and increases on two or more lab determinations
Individual has post-operative stage T3b to T4
Individual’s post-operative pathology reveals positive surgical margins
Other (Please list);
Other (Please list);
Head and neck cancer
Oral Cavity, Lips, or Pharynx (oropharynx, hypopharynx, or nasopharynx)
Larynx cancer (Stage I and II)
Larynx cancer (Stage III or IV)
Nasal cavity or paranasal sinuses
Salavary glands
Mucosal melanoma arising in head and neck region
Occult primary arising in the head and neck region
Tracheal
Cervical esophagus
Lymphoma arising in the head and neck region
Thyroid arising in the neck region
Other (Please list);
REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Coverage Guideline RAD.00041
Policy Last Review Date: 05/07/2015
Policy Effective Date:
07/07/2015
Provider Tool Effective Date: 07/07/2015
Thyroid cancer
Anaplastic thyroid cancer
Papillary
Follicular
Other thyroid cancer:
Central Nervous System (CNS) primary or metastatic lesions. (Check the following when it applies)
Located in close proximity to optic nerve, lens, retina, optic chiasm, cochlea, or brainstem
Pediatric individual less than 21 years old with a radiosensitive tumor
Cancer of the anus or anal canal
Primary malignant gynecologic tumor (uterus, cervix, ovary, fallopian tube)
Primary pelvic sarcoma
Bladder carcinoma
Rectal adenocarcinoma
Individual who requires repeat irradiation of a field that has received prior irradiation
Breast cancer (check all that apply)
Individual with left sided breast lesions
Target volume coverage results in cardiac radiation exposure that is expected to be greater than
or equal to 25 Gy to 10cc or more of the heart (V25 greater than or equal to 10cc) with 3D
conformal RT despite the use of a complex positioning device (such as VAC-LokTM)
With the use of intensity modulated radiation therapy (IMRT), there is a reduction in the
absolute heart volume receiving 25 Gy or higher by at least 20% (for example, volume predicted
to receive 25 Gy by 3D RT is 20cc and the volume predicted by IMRT is 16 cc or less)
Other (Please list);
Individual with large breasts when the treatment planning with 3D conformal results in hot spots (focal
regions with dose variation greater than 10% of target) and the hot spots can be avoided with IMRT.
Individual to receive internal mammary node irradiation
Pathologically enlarged internal mammary
lymph node(s) as reported based on imaging technique by CT, MRI, PET/CT or CXR
Pathologically involved internal mammary lymph node(s) (based on aspiration cytology or tissue
biopsy pathology)
Individual is high risk for internal mammary lymph node involvement based on:
Greater than or equal to 4 positive axillary lymph nodes
Medial quadrant tumor with 1 or more positive axillary lymph nodes
Medial quadrant T3 tumor
Other (Please list);
REVIEW REQUEST FOR
Intensity Modulated Radiation Therapy (IMRT)
Provider Data Collection Tool Based on Coverage Guideline RAD.00041
Policy Last Review Date: 05/07/2015
Policy Effective Date:
07/07/2015
Provider Tool Effective Date: 07/07/2015
Lung cancer (check all that apply)
Individual with primary lung cancer where concurrent chemotherapy and radiation is to be used
Percent of normal lung receiving more than 20 Gy (V20)accounts for more than 35% of the normal
lung, defined as the total lung volume minus the planning target volume (PTV)
The IMRT plan will reduce the V20 to at least 10% below the V20 that is achieved with the 3D
conformal plan (for example, from 40% down to 30% or lower)
There is documentation that the treatment plan addresses tumor motion that is both accounted for and
managed such as: (check all that apply)
A 4D planning CT scan was performed and the primary tumor and included lymph nodes were
observed to move less than 1 cm and this degree of motion was included in the planning tumor
volume
A 4D planning CT scan was performed and respiratory gating will be employed to minimize the
risk of inadequate coverage.
A 3D planning CT scan was performed with free-breathing, end-inspiration and end-expiration
breath-hold to minimize risk of inadequate coverage
Other (Please list);
Abdominal cancer
Cancer of unknown primary
Treatment of large arteriovenous malformations (AVM)
Other (Please list);
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.