Denied today. Paid without touching it.

Request for full overturn

Regional Medical Center requests immediate reversal of the medical necessity denial and reprocessing of the above claim. This motion is grounded in the source clinical record, claim history, authorization trace, payer denial notice, and the applicable provider-appeal and IMRT policy framework mapped to this case. A written response is requested within the timeframe specified in the provider agreement and applicable state prompt-payment regulations.

Clinical and claim summary

The denied account reflects definitive radiation treatment for oropharyngeal squamous cell carcinoma (ICD-10 C10.9) with bilateral neck coverage. The record contains the radiation oncology consult, physician order, simulation note, inverse-planned IMRT treatment plan, dose-volume histogram set, and the signed course prescription showing total dose and dose per fraction across the treatment dates listed above. The claim history, billed units (CPT 77301; CPT 77385 × 33), and dates of service reconcile to the treatment course. No duplicate, bundling, or timing variance was identified in the pre-release claim audit.

Why the denial is incorrect

First, the payer IMRT coverage policy lists head and neck cancers — including oropharyngeal primaries — as covered indications for definitive IMRT when the clinical record supports medical necessity. Second, the attached documentation satisfies every element the policy requires: confirmed diagnosis, delineated target volumes, total dose, dose per fraction, inverse-planning method, and a narrative statement explaining why IMRT is required over conventional or 3D conformal radiation therapy. Third, the comparative planning evidence demonstrates that the organs-at-risk constraints for this case — parotid glands, spinal cord, and mandible — cannot be met at the prescribed dose with a non-IMRT technique. Fourth, the CARC 50 denial cannot be sustained on clinical or administrative grounds: authorization was in place, claim lines reconcile to the treatment course, and no coverage exclusion applies to this diagnosis or treatment setting.

Contract and process crosswalk

This reconsideration was submitted through the payer's first-level reconsideration channel in accordance with the provider agreement and applicable administrative guide. Claim identifiers, dates of service, billed amount, and reason for disagreement were populated per payer instructions. The denial notice, EOB copy, and supporting clinical and administrative records were attached prior to release. In production, Sirrus binds this section to the live provider agreement, state-specific dispute instructions, and plan-level administrative guide associated with the account.

Requested relief and next steps

Please overturn the denial in full, reprocess the claim consistent with the submitted records, and issue corrected payment for CPT 77301 and CPT 77385 × 33. If any additional clinical or administrative documentation is required, please identify it specifically in your written response. Any supplemental documentation request will be fulfilled promptly — the submitting platform retains all supporting records and can release a supplemental packet without delay. If this reconsideration is denied in whole or in part, please provide the specific clinical rationale and policy basis for each denied service so that a formal second-level appeal or external review request can be prepared.

Attachment set released with this motion

• Copy of denial notice, EOB, and 835 remittance excerpt (CARC 50 / RARC MA01)
• Radiation oncology consult note and signed physician order
• Simulation note and treatment course summary
• Inverse-planned IMRT treatment plan and comparative 3D planning artifacts
• Dose-volume histograms and dose / fraction schedule
• Authorization trace and episode timeline
• Claim-line, CPT code, and date-of-service reconciliation worksheet
• Payer IMRT coverage policy crosswalk (illustrative)