CO-61 applies a penalty where the plan required a second surgical opinion before an elective procedure and none was obtained. It is a plan condition rather than a clinical judgement, and it usually reduces rather than denies payment.
What CO-61 means
Second-opinion requirements attach to a defined list of elective procedures and are set out in the plan document rather than in a medical policy. Because they are now rare, they are frequently missed at scheduling. The exceptions that matter are urgency — where delay for a second opinion was not clinically appropriate — and cases where the opinion was in fact obtained but never reported to the payer.
Why CO-61 fires
- The plan required a second opinion for this procedure and none was recorded.
- An opinion was obtained but not submitted to the payer.
- The procedure was urgent and the requirement was applied anyway.
- Nobody flagged the second-opinion condition when the case was booked.
Is CO-61 worth appealing?
Sometimes worth appealing
How to resolve or appeal CO-61
- 1
Check whether an opinion exists
A consultation in the referral chain frequently satisfies the requirement and was simply never reported.
- 2
Argue urgency where it applies
With the record showing why delay was not appropriate.
CO-61 — frequently asked
Are second-opinion requirements still used?
Can the patient be billed?
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-61 denial into a signed appeal
Upload the denied EOB and Merits builds a complete CO-61 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.