Diagnosis coverage appealable with evidence

Denial Code CARC 167: This (these) diagnosis(es) is (are) not covered

CARC 167 means: this (these) diagnosis(es) is (are) not covered. Here's what it means in plain English, why it happens, and how it's worked toward payment.

CARC 167 — This (these) diagnosis(es) is (are) not covered. Denial family: Diagnosis coverage.

Why you get a CARC 167 denial

The submitted diagnosis isn't on the payer's covered list for that service.
A more specific or different supported diagnosis applies.
The coverage policy (LCD/medical policy) excludes the dx as billed.

How to fix or appeal CARC 167

Check the payer's coverage policy for covered diagnoses.
If a supported diagnosis applies, correct the coding and rebill.
If the billed dx is correct and medically supported, appeal with records and the policy cross-walk.

Recoverable when a supported diagnosis applies or the record justifies coverage under the policy.

Have a stack of CARC 167 (or other) denials piling up? Get a free forensic A/R audit →

CARC 167 — FAQ

Why was my diagnosis not covered (CARC 167)?

The payer's policy doesn't list the billed diagnosis as covered for that service. Verify whether a more specific, supported diagnosis applies, or appeal with documentation.

Can CARC 167 be appealed?

Yes, when the clinical record supports coverage — cross-walk the documentation to the payer's coverage policy.