CO-167
CO · Contractual Obligation
CO-167 Denial Code: Payer doesn't cover the billed diagnosis
The payer doesn't cover the reported diagnosis for this service under its policy. Often a more specific or additional documented diagnosis supports coverage - or it's appealable with records.
- Group code
- CO - Contractual Obligation
- Code type
- CARC
- Billable to patient?
- No - contractual write-off
- Appealable?
- Often, with documentation
- Category
- Medical Necessity
- Common pairing
- N130
On a remittance
CAS*CO*167*125.00On a paper EOB it shows as CO-167.What CO-167 means
CO-167 means the diagnosis on the claim isn't on the payer's covered list for the service - closely related to CO-50 (medical necessity), but specifically about the diagnosis. Frequently a more specific or additional documented diagnosis would support coverage. Compare the billed diagnosis to the payer's policy (an LCD or NCD for Medicare) and correct or appeal.
Common causes
- The reported diagnosis isn't a covered indication for the service under the payer's policy.
- A more specific or supporting diagnosis that's documented wasn't coded.
- The diagnosis was coded to an unsupported level of specificity.
- The service is considered screening or experimental for the diagnosis given.
How to fix it
- Pull the applicable coverage policy (LCD/NCD or payer medical policy) and compare its covered diagnoses to what you billed.
- If a supported diagnosis is documented but wasn't coded, submit a corrected claim with it.
- If the diagnosis is supported, appeal with the chart notes that establish coverage.
- If truly not covered and notice was given, bill per the ABN/notice rules.
How to prevent it
- Check covered diagnoses for policy-sensitive services at the point of order.
- Code diagnoses to the highest specificity the documentation supports.
- Use ABNs where a diagnosis may not meet coverage criteria.
Often, with documentationStrongly appealable when the documentation supports a covered diagnosis. Cite the specific coverage policy and attach the records, or submit a corrected claim with the supported diagnosis.
Linked CMS edit: LCD/NCDFor Medicare, compare the billed diagnosis against the covered-diagnosis list in the applicable Local Coverage Determination (LCD) or National Coverage Determination (NCD) in the Medicare Coverage Database.
Appeal letter template
Fill in the bracketed fields, attach your supporting documentation, and send through the payer's appeal channel. This is a starting point — adjust to your payer's requirements.
Re: Diagnosis Coverage Appeal (CO-167) - Claim [Claim Number] Patient: [Patient Name] | Member ID: [Member ID] Date(s) of Service: [DOS] | Service: [CPT/HCPCS] | Diagnosis: [ICD-10] To Whom It May Concern: Claim [Claim Number] was denied under CO-167 (diagnosis not covered). Per [LCD/NCD/Policy Number], diagnosis [ICD-10] is a covered indication for [CPT/HCPCS], and it is documented in the enclosed records: [brief clinical rationale]. We request reconsideration and payment. Supporting documentation is enclosed. Sincerely, [Your Name], [Practice Name] | [Phone] | [NPI/TIN]