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CARC 167 · CO-167

CARC 167 Denial: This (these) diagnosis(es) is (are) not covered — How to Fix and Appeal

Reviewed by QuickIntell RCM Editorial Team · Last reviewed

Updated

TL;DR

CARC 167 (X12 This (these) diagnosis(es) is (are) not covered). CARC 167 means the specific ICD-10 diagnosis billed is not covered by the payer — either under this plan's exclusions or under a medical-policy rule that limits coverage to a subset of diagnoses.

Official X12 description

“This (these) diagnosis(es) is (are) not covered.”

Source: X12 Claim Adjustment Reason Codes. The X12 External Code Lists are the single authoritative source for every CARC descriptor — always verify against the current release before building a claim-scrub rule.

What CARC 167 actually means

CARC 167 means the specific ICD-10 diagnosis billed is not covered by the payer — either under this plan's exclusions or under a medical-policy rule that limits coverage to a subset of diagnoses. This overlaps with CARC 11 (diagnosis-procedure inconsistency) and CARC 50 (medical necessity), but CARC 167 targets the diagnosis itself rather than the pairing. Verify the chart; if a covered diagnosis is supported, submit a corrected claim.

Common root causes

  • Diagnosis is plan-excluded (cosmetic, mental-health carve-out, workers-comp-only diagnoses billed to health).
  • Diagnosis falls outside an LCD or commercial medical policy's covered list.
  • Diagnosis coded at insufficient specificity and the unspecified code is not covered.

Prevention checklist

  • Specialty-specific covered-diagnosis lookups in the charge-capture workflow.
  • ICD-10 specificity training for conditions where the unspecified code is commonly denied (chest pain, abdominal pain, dizziness).
  • Pre-authorization for diagnoses that a payer flags as medical-policy reviewed.

Appeal strategy — step by step

Most CARC 167 denials clear faster with the right remediation than with a formal appeal. Work the steps in order and escalate only when a lower-effort path has been ruled out.

  1. 1If a covered diagnosis is present in the record, submit a corrected claim.
  2. 2If the billed diagnosis is the only clinically accurate one and the payer's policy excludes it, appeal with the clinical justification and a citation to any conflicting clinical guideline.
  3. 3For Medicare LCD denials, check the Group 2/Group 3 diagnosis lists in the LCD article — sometimes a specific ICD is covered under a different Group.
Sample appeal-letter language for CARC 167
[Provider letterhead] Re: Appeal of CARC 167 — Claim #{claim_number} Member: {member_name} · Member ID: {member_id} Date(s) of Service: {dos} On {remittance_date} this claim was adjusted with CARC 167: "This (these) diagnosis(es) is (are) not covered." We respectfully request reconsideration. The X12 External Code List definition of CARC 167 does not apply to this claim for the following reasons: 1. [Cite the clinical / coding / policy fact that rebuts the adjustment] 2. [Cite the supporting documentation attached — op note, EOB, LCD/NCD citation, NCCI edit indicator, modifier rationale] 3. [Cite the payer's own policy where applicable] Attached: {list supporting documents} Please process payment under the member's benefits. If additional information is required, contact the billing office at {provider_phone} or {provider_email}. Sincerely, {billing_manager_name}, {credentials}

Edit the bracketed fields before sending. This template is a starting point; a payer-specific appeal form may still be required — check the provider portal first.

Payer-specific notes

Payer-specific behavior for CARC 167 publishes here as the QuickIntell anonymized denial ETL ingests sufficient volume. In the meantime, consult the payer directory for the relevant provider manual and appeal form.

How common is CARC 167?

Search demand rank
#44

Out of 306 seeded CARCs, ranked by combined US monthly search volume for "CARC 167", "CO-167 denial", and "denial code 167".

Platform frequency
Pending ETL

Platform frequency ranks publish once the anonymized denial-rate pipeline reaches the publication threshold (strategy §12 Phase 2).

How QuickRCM prevents CARC 167

QuickRCM catches the root causes above before the 837 leaves the clearinghouse:

  • Claim-scrub rules fire on every root cause listed above — the scrub references the same X12 CAS segment logic that drives the denial, so what the payer checks, QuickRCM checks first.
  • When a denial lands, QuickRCM routes it to the correct worker with the documentation bundle already attached (op note, LCD citation, modifier rationale, EOB, primary 835).
  • Appeal templates tuned to each CARC (including this one) pull the supporting facts from the claim and fill the bracketed fields automatically.
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Frequently asked questions — CARC 167

What does CARC 167 mean?

CARC 167 is an X12 Claim Adjustment Reason Code. The official definition is: "This (these) diagnosis(es) is (are) not covered." In plain English, the payer is telling you cARC 167 means the specific ICD-10 diagnosis billed is not covered by the payer — either under this plan's exclusions or under a medical-policy rule that limits coverage to a subset of diagnoses. This overlaps with CARC 11 (diagnosis-procedure inconsistency) and CARC 50 (medical necessity), but CARC 167 targets the diagnosis itself rather than the pairing. Verify the chart; if a covered diagnosis is supported, submit a corrected claim.

How do I resolve a CARC 167 (CO-167) denial?

Start with the most common root cause: Diagnosis is plan-excluded (cosmetic, mental-health carve-out, workers-comp-only diagnoses billed to health). First step: If a covered diagnosis is present in the record, submit a corrected claim. See the full remediation and appeal checklist on this page before filing a formal appeal.

Is CARC 167 patient responsibility?

No — CARC 167 is typically carried under CO (Contractual Obligation) or OA (Other Adjustment), which means it is the provider's responsibility, not the patient's. Do not bill the patient unless the 835 CAS group code is PR.

What does CARC 167 look like on an EOB or 835 remittance?

On the 835 ERA, CARC 167 appears in Loop 2110 CAS segment as "CAS*CO*167*{amount}". On a paper EOB the same code prints in the Adjustment/Denial Reason column with the X12 description: "This (these) diagnosis(es) is (are) not covered." — usually paired with one or more RARC remark codes in the same remittance line for additional context.

Which RARC is paired with CARC 167?

CARC 167 is commonly observed with RARC N115, N130. The RARC narrows the reason — for example, pointing at a missing modifier, an LCD citation, or a specific policy. Fix the underlying CARC first; the RARC usually clears with the corrected claim.

Disclaimer

This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. X12 code descriptors are maintained by the X12 External Code Lists; always verify against the current X12 release and the payer's own published policy before submitting or appealing a claim.