Brain Metastases Radiation Therapy Physician Worksheet (As of 31

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Brain Metastases Radiation Therapy Physician Worksheet (As of 31
Brain Metastases Radiation Therapy Physician Worksheet (As of 31 January 2017) This worksheet is to be used for treatment of brain metastases. If the treatment is for the primary cancer or
another metastases, please use the appropriate metastatic worksheet.
Patient name:
What is the radiation therapy treatment start date (mm/dd/yyyy)?
1.
______ /______ /______
Is whole brain radiation therapy (WBRT) with complex (77307) technique
Yes
and a maximum of 10 fractions being requested*?
No
*If yes, no further information is required. If no, please continue.
2.
What is the primary site?
Bladder
Colorectal
Lung
Sarcoma
Breast
Head/Neck
Melanoma
Other: __________
Gynecological
Kidney
Pancreas
3.
Is the primary tumor controlled?
4.
Are non-brain visceral metastases (e.g. lung, liver, etc.) present on the
most recent radiologic studies?
5.
a. Is the patient receiving chemotherapy or other systemic treatment?
Yes
No
Yes
No
Yes
No
b. If no, why is the patient not receiving chemotherapy or other systemic treatment?
The non-brain metastatic disease is stable; and therefore, not requiring systemic therapy
There are no good systemic treatment options
The patient is refusing systemic therapy
The patient’s performance status does not allow for the delivery of systemic therapy
6.
What is the
0
patient’s
ECOG
1
performance
status?
2
3
4
Fully active, able to carry on all pre-disease performance without restriction.
Restricted in physically strenuous activity but ambulatory and able to carry out
work of a light or sedentary nature, e.g., light house work, office work.
Ambulatory and capable of all self-care but unable to carry out any work
activities. Up and about more than 50% of waking hours.
Capable of only limited self-care, confined to bed or chair more than 50% of
waking hours.
Completely disabled. Cannot carry on any self-care. Totally confined to bed or
chair.
Continued on next page
Brain Metastases Radiation Therapy Physician Worksheet (As of 31 January 2017) 7.
a. Has the brain previously been treated with radiation therapy?
Yes
No
b. If yes, what type of radiation therapy was previously used to treat the patient?
Previous whole brain radiation therapy (WBRT)
Previous stereotactic radiosurgery (SRS)
8.
If previous WBRT was used to treat the patient, then answer the following questions:
a. Was the last WBRT fraction delivered in the past 3 months?
b. What is the date of the last WBRT treatment?
9.
Yes
No
______ /______ /______
If SRS was previously used to treat the patient, then answer the following questions:
a. Was the last SRS session delivered in the past 6 months?
b. What is the date of the last SRS treatment?
10.
How many active brain lesions are visible on the most recent MRI?
11.
What is the treatment plan?
Yes
No
______ /______ /______
1-3
4 or more
Whole brain
Partial brain
12.
If whole brain is the selected treatment plan, then answer the following set of questions:
a. What treatment technique will be used for WBRT?
Complex (77307)
3D conformal
Intensity modulated radiation therapy (IMRT)
Tomotherapy
b. How many whole brain fractions will be delivered?
c. Is a concurrent boost being delivered? If yes, answer questions
corresponding to partial brain below.
Fractions: __________
Yes
No
Continued on next page
Brain Metastases Radiation Therapy Physician Worksheet (As of 31 January 2017) 13.
If partial brain is the selected treatment plan, then answer the following set of questions:
a. Is only partial brain being treated (no WBRT)?
Yes
No
b. Is this a boost in conjunction with WBRT?
Yes
No
c. What is the treatment technique for the partial brain treatment?
Complex (77307)
3D conformal
Proton beam therapy
Intensity modulated radiation therapy (IMRT)
Tomotherapy
Stereotactic radiosurgery (SRS)
d. How many partial brain fractions will be delivered?
Fractions: __________
Please note that 3D technique is not considered medically necessary for standard 2 field whole brain
treatment, and 77295 will not be reimbursed.
14.
Note any additional information in the space below.

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