CARC CO-167This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 8...2026 Appeals, Prevention & Recovery Guide
Root Causes
Why CO-167 fires. Understanding the cause is the first step. Fix the cause, not just the symptom.
The diagnosis or diagnoses are not covered. The payer excludes the submitted diagnosis from coverage for this service under its benefit design or coverage policy.
- The diagnosis is not on the covered list for the benefit (common with screening, preventive, and elective services)
- The diagnosis points to a condition the plan excludes, such as cosmetic indications
- A covered diagnosis is supported by the record but a non-covered one was coded instead
- The diagnosis was coded to an unspecified category that the policy does not accept
Quick Reference
Appeal Strategy
What to attach, what to skip, and where to file. Built from CERT and RAC reports plus major payer manuals.
Treat CO-167 as a coverage-policy question:
- Compare the billed diagnosis against the LCD, NCD, or commercial medical policy covered-diagnosis list
- If the record supports a covered diagnosis that was miscoded, correct the ICD-10 and resubmit with documentation
- If the underlying condition is genuinely excluded from the benefit, the service is not payable and may become patient responsibility when proper advance notice was given
As with any diagnosis denial, never code a diagnosis the documentation does not support.
60 percent of denied claims are never resubmitted. That is permanent revenue loss. Our denial management services work every CO-167 line under aging buckets, file appeals within 48 hours, and recover what most billers write off.
Prevention Workflow
The cheapest denial is the one that never fires. Build these checks into the front-end workflow.
Check covered-diagnosis lists before scheduling elective or borderline services. Obtain an advance beneficiary notice when coverage is doubtful so the patient balance is protected. Code to the highest specificity the documentation supports, since unspecified codes are a frequent trigger.
Practices that build CO-167 prevention into eligibility, scrubber rules, and charge-capture see 40 to 70 percent reduction in this denial type within 90 days. Catch upstream beats appeal downstream every time.
The cost of denials, in real numbers
Find the recoverable revenue hiding in your CO-167 denials.
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Everything about CO-167
What does denial code CO-167 mean?
This (these) diagnosis(es) is (are) not covered. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present
Can CO-167 be appealed successfully?
Overturn rate: Moderate when a covered diagnosis is supported but was miscoded; low when the underlying condition is excluded from the benefit. Successful appeals require documentation that directly addresses the payer's stated reason for denial. See the Appeal Strategy section for the exact attachments and modifier paths that win.
How do I prevent CO-167 denials?
Check covered-diagnosis lists before scheduling elective or borderline services. Obtain an advance beneficiary notice when coverage is doubtful so the patient balance is protected. Code to the highest specificity the documentation supports, since unspecified codes are a frequent trigger.
CARC codes maintained by X12 N. Overturn rates reflect aggregated CERT, RAC, and payer-published data. Actual results vary by payer, contract, and clinical specifics. Curated content reviewed by AAPC-certified coders.
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