How to Appeal PR-55 Denial: Experimental treatment — patient responsibility
The service was denied as experimental and the cost has been assigned to the patient. This guide explains what it means, why it happens, and exactly how to build a winning appeal.
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What Does PR-55 Mean?
The service was denied as experimental and the cost has been assigned to the patient.
Commonly seen in:
Step-by-Step Appeal Guide for PR-55
- 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 PR-55 denials.
Do not bill the patient until the appeal process is exhausted
Appeal with peer-reviewed literature, clinical guidelines, and FDA information
Request external independent medical review
For clinical trials, cite ACA Section 2709 requiring coverage of routine clinical trial costs
Regulations and Guidelines to Cite
Citing specific regulations strengthens your appeal and demonstrates you know your rights.
Expert Tip for PR-55 Appeals
ACA Section 2709 requires coverage of routine costs associated with approved clinical trials. If the patient is in a qualifying trial, this may apply.
Frequently Asked Questions
What is a PR-55 denial code?
The service was denied as experimental and the cost has been assigned to the patient.
Can I appeal a PR-55 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 PR-55?
For a PR-55 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 PR-55 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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