How to Appeal CO-240 Denial: Medicare coverage criteria not met
The diagnosis does not meet the coverage criteria in the Medicare Coverage Issues Manual, the Medicare Hospital Manual, or the Medicare Coverage Database. This guide explains what it means, why it happens, and exactly how to build a winning appeal.
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What Does CO-240 Mean?
The diagnosis does not meet the coverage criteria in the Medicare Coverage Issues Manual, the Medicare Hospital Manual, or the Medicare Coverage Database.
Commonly seen in:
Step-by-Step Appeal Guide for CO-240
- 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-240 denials.
Obtain the specific LCD/NCD used for the denial
Document that the patient meets all clinical indications in the coverage policy
Request a contractor medical director review
For NCDs, document any clinical exceptions allowed under the coverage policy
Regulations and Guidelines to Cite
Citing specific regulations strengthens your appeal and demonstrates you know your rights.
Expert Tip for CO-240 Appeals
Pull the exact LCD from the CMS Coverage Database and address each indication point-by-point in your appeal. Vague appeals rarely succeed with Medicare.
Frequently Asked Questions
What is a CO-240 denial code?
The diagnosis does not meet the coverage criteria in the Medicare Coverage Issues Manual, the Medicare Hospital Manual, or the Medicare Coverage Database.
Can I appeal a CO-240 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-240?
For a CO-240 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-240 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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