CARC55ReferenceCurrentVerified Aug 15, 2026CARC 55
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 procedure, treatment or drug is deemed experimental or investigational by the payer.
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
- Service not proven per the payer's technology assessment
- Service considered investigational under the plan
AR Guide knowledge
What AR should verify
- Review the payer's policy on the specific service
- Gather peer-reviewed evidence supporting the service
AR Guide knowledge
Recommended action
- Appeal with clinical evidence and supporting literature
- Check if the plan covers the service under a clinical trial or exception process
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.