PR-167: This (these) diagnosis(es) is (are) not covered.

Why it fires

• The diagnosis code is on the payer's non-covered or excluded list for this benefit
• The ICD-10 code does not match any diagnosis accepted under the relevant LCD, NCD, or medical policy
• A more specific or different diagnosis code should have been used based on the documentation

Corrective actions, ranked

1. 1

   Check the LCD or medical policy

   Compare the billed diagnosis against the payer's covered diagnosis list for this procedure.

2. 2

   Query for a more accurate diagnosis

   If documentation supports a covered, more specific ICD-10 code, obtain clarification from the ordering provider and rebill.

3. 3

   Notify the patient in advance next time

   For known non-covered diagnoses, get an ABN or equivalent waiver before the service so the patient can be billed appropriately.

Is it worth appealing

Appeal with clinical documentation when the correct, more specific diagnosis is actually covered and was simply coded imprecisely.

Remark codes that arrive with it

A RARC carries the detail behind PR-167. These are the ones our dataset records alongside it.

• N130Consult plan benefit documents/guidelines for information about restrictions for this service

Other denial codes to check

Codes that share a remark code with this one, or that are reported under the same group code.

• PR-204This service/equipment/drug is not covered under the patient's current benefit plan
• PR-96Non-covered charge(s).
• PR-50These are non-covered services because this is not deemed a 'medical necessity' by the payer.
• PR-151Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
• PR-1Deductible Amount
• PR-2Coinsurance Amount

See every CARC in the dataset