How to Appeal CO-167 Denial: Diagnosis not covered by this payer
The diagnosis code is not recognized or covered by the payer for the service billed. This guide explains what it means, why it happens, and exactly how to build a winning appeal.
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What Does CO-167 Mean?
The diagnosis code is not recognized or covered by the payer for the service billed.
Commonly seen in:
Step-by-Step Appeal Guide for CO-167
- 1
Request the specific clinical criteria or LCD/NCD the payer used to deny the claim
- 2
Obtain all relevant clinical documentation: progress notes, lab results, imaging, referrals
- 3
Have the treating provider write a letter of medical necessity addressing the denial criteria
- 4
Cite applicable LCDs, NCDs, and peer-reviewed literature supporting the treatment
- 5
Submit the appeal with all documentation and request a peer-to-peer review if available
Counter-Arguments to Use in Your Appeal
These are the strongest arguments medical billing professionals use to overturn CO-167 denials.
Verify the ICD-10 code is valid and specific enough
Provide clinical documentation supporting the diagnosis
Reference LCDs/NCDs that list the diagnosis as covered
If using a new ICD-10 code, provide a crosswalk to the previous code
Regulations and Guidelines to Cite
Citing specific regulations strengthens your appeal and demonstrates you know your rights.
Expert Tip for CO-167 Appeals
Z-codes (screening/preventive) are frequently denied when they should be covered under ACA preventive care mandates.
Frequently Asked Questions
What is a CO-167 denial code?
The diagnosis code is not recognized or covered by the payer for the service billed.
Can I appeal a CO-167 denial?
Yes. All insurance denials are appealable. Follow the step-by-step guide above and submit your appeal before the payer's deadline, typically 180 days from the denial date.
What documentation do I need to appeal CO-167?
For a CO-167 denial, you typically need: the original denial letter/EOB, clinical documentation supporting the service, any prior authorization records, and a cover letter citing the relevant regulations listed above. The specific documents depend on why the denial was issued.
How long does a CO-167 appeal take?
Most payers are required to process standard appeals within 30–60 days. Expedited appeals (for urgent care) must be decided within 72 hours. Under ERISA, group health plans must provide an appeal decision within 60 days for pre-service and 60 days for post-service claims.
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