How to Appeal CO-46 Denial: Non-covered service
The service billed is not covered under the patient's benefit plan. This guide explains what it means, why it happens, and exactly how to build a winning appeal.
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What Does CO-46 Mean?
The service billed is not covered under the patient's benefit plan.
Commonly seen in:
Step-by-Step Appeal Guide for CO-46
- 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-46 denials.
Request the exact benefit plan exclusion language
Verify whether a different procedure code may be covered for the same service
Cite relevant mandated benefit laws in your state
Provide peer-reviewed evidence that the service is standard of care
Regulations and Guidelines to Cite
Citing specific regulations strengthens your appeal and demonstrates you know your rights.
Expert Tip for CO-46 Appeals
Request the specific SPD exclusion language in writing. Vague 'not covered' responses are often challengeable.
Frequently Asked Questions
What is a CO-46 denial code?
The service billed is not covered under the patient's benefit plan.
Can I appeal a CO-46 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-46?
For a CO-46 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-46 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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