CO-167 / PR-167

Diagnosis not covered

The plan doesn't cover care for the diagnosis as coded. A more specific or additional diagnosis code may fix it.

Official meaning (X12 code 167): This (these) diagnosis(es) is (are) not covered.

Who pays

CO-167. Contractual obligation: the provider's contract with your plan makes this the provider's write-off. An in-network provider generally can't bill you for a CO amount.

PR-167. Patient responsibility: the plan says this part is yours to pay (deductible, copay, coinsurance, or a non-covered service).

What to do

Ask the provider whether the diagnosis was coded fully.
If it was, appeal with the plan language and your doctor's letter.

If you appeal

Ask for the plan document section the denial relies on. Denials often hinge on a definition that your situation fits better than the reviewer assumed. State mandates may also require coverage.

What the appeal asks for: Identify the specific plan provision relied on and reconsider, as the service falls within covered benefits.

Basis: 29 CFR §2560.503-1(g)(1)(ii)

Deadlines for the first appeal

employer plan: 180 days from the notice
ACA Marketplace plan: 180 days from the notice
Medicare Advantage plan: 65 days from the notice
Original Medicare: 120 days from the notice
Medicaid: 60 days from the notice

The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.

What the data show

11.5%Only 11.5% of denied Medicare Advantage prior authorization requests were appealed in 2024. KFF, 2024 data

80.7%80.7% of appealed Medicare Advantage prior authorization denials were partially or fully overturned in 2024. KFF, 2024 data

<1% (262,982 appeals)Fewer than 1% of denied in-network marketplace claims were appealed in 2024 (at least 262,982 appeals). KFF, 2024 data

66% upheldInsurers upheld 66% of denials on internal appeal in 2024 (165,863 denials). KFF, 2024 data

13%13% of in-network marketplace denials were because the claim was for an excluded service. KFF, 2024 data

Averages across all denials; not a prediction for yours.

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General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.