CARC167ReferenceCurrentVerified Aug 15, 2026CARC 167
AR Guide Workflow
Medical Necessity
The payer determined the service was not medically necessary or reasonable according to its policy. These denials are documentation-driven.
AR Guide explanation
What it means
The diagnosis or diagnoses submitted are not covered.
AR Guide knowledge
Common denial category
Medical Necessity — The payer determined the service was not medically necessary or reasonable according to its policy. These denials are documentation-driven.
AR Guide knowledge
Common causes
- Diagnosis excluded by the plan or policy
- Diagnosis does not meet coverage criteria
AR Guide knowledge
What AR should verify
- Identify the excluded diagnosis
- Review the plan/policy coverage criteria for the diagnosis
AR Guide knowledge
Recommended action
- Appeal with clinical documentation supporting the diagnosis
- If the diagnosis code is wrong, correct and resubmit
About this guidance: Note
AR Guide knowledge is general reference content written by our team — it is not payer-specific policy and never replaces the payer’s documentation or your contract. Always confirm specifics with the payer.