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CO-167
Recoverability: Medium
This (these) diagnosis(es) is (are) not covered
The plan does not cover services for the diagnosis reported. On dental claims this appears mostly on medically billed dentistry and on plans that require diagnosis codes for specific procedures.
Why this happens on dental claims
- Medical claims for TMJ therapy, bruxism appliances, or sleep apnea devices where the plan excludes those diagnoses
- Trauma or pathology claims coded with an unspecified diagnosis the plan cannot map to a covered condition
- The wrong primary diagnosis leading adjudication, with the covered condition buried in a secondary position
How to appeal CO-167
- Confirm the diagnosis from the clinical record and check whether a more specific, accurate code describes the covered condition
- Reorder diagnosis codes so the covered primary condition leads the claim, and submit a corrected claim
- If the diagnosis is accurate but excluded, review the plan's exclusion language for exceptions such as accident or congenital conditions
- Appeal with clinical documentation tying the treatment to a covered condition where one genuinely exists
How to prevent it
- Code to the highest documented specificity on medically billed claims, and confirm covered diagnoses in the plan policy before treatment
Related codes
How much CO-167 money is sitting in your remittances?
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