CO-167CO group · Medical necessity

CO-167 denial code: this diagnosis is not covered

CO-167 says the diagnosis isn't a covered indication for the service. Like CO-11, it's often a specificity or documentation gap rather than a true non-coverage.

CO-167 means the diagnosis (or diagnoses) reported is not covered for the service billed. Payers decide this against a coverage policy that lists supported indications. It is appealable when the record documents a covered indication that wasn't coded — or when the policy supports the diagnosis and the denial was applied in error.

What CO-167 means

Coverage policies (LCDs or plan medical policies) define which diagnoses make a service payable. If the claim's diagnosis isn't on that list, the service denies as CO-167. As with CO-11, the patient frequently has a covered indication that was under-coded or omitted from the claim.

Why CO-167 fires

  • The reported diagnosis isn't a supported indication under the coverage policy.
  • A covered diagnosis in the record wasn't coded or pointed to the service.
  • The diagnosis lacks the specificity the policy requires.
  • The service genuinely isn't covered for the patient's condition.

Is CO-167 worth appealing?

Sometimes worth appealing

Appealable when the record supports a covered indication. Pull the coverage policy, confirm which diagnoses it supports, and either correct the coding (if a covered diagnosis is documented but uncoded) or appeal with the chart note plus a citation to the policy language. If the condition truly isn't a covered indication, the denial usually stands.

How to resolve or appeal CO-167

  1. 1

    Read the coverage policy's covered diagnoses

    Find the LCD or plan medical policy and its list of supported ICD-10 codes for the service.

  2. 2

    Correct under-coding

    If the record documents a covered diagnosis that wasn't submitted, send a corrected claim with the right codes and pointers.

  3. 3

    Appeal with record + citation

    When documentation already supports a covered indication, appeal with the note and the exact policy language listing that diagnosis as covered.

CO-167 — frequently asked

How is CO-167 different from CO-11?
CO-11 flags a diagnosis/procedure inconsistency; CO-167 specifically says the diagnosis isn't covered for the service. Both are resolved against the coverage policy.
Can I change the diagnosis to get paid?
Only to a diagnosis the record supports. Selecting a covered code the documentation doesn't substantiate is improper coding.

Related guides

CO-50 · Medical necessityCO-11 · CodingCO-204 · Benefit

Sources

Reason-code meanings are paraphrased from the X12 Claim Adjustment Reason Code list for plain-language reference; they are not reproduced verbatim. This is general information, not legal, coding, or medical advice — always confirm against the payer's remittance and policy.

Turn this CO-167 denial into a signed appeal

Upload the denied EOB and Merits builds a complete CO-167 appeal — the argument, the payer's own coverage criteria, and your federal appeal rights, every claim cited to a named source. $9 a letter. No account.

Appeal a denial →