CARC 167: This (these) diagnosis(es) is (are) not covered.
The diagnosis code itself is excluded from coverage under your plan.
CARC 167 is the code your insurance company used to explain why your claim was reduced, denied, or paid less than expected. It appears on your Explanation of Benefits (EOB) — the statement your plan sends after a claim is processed. Here's what it means for you and what you can do about it.
What CARC 167 means
The official X12 description is: “This (these) diagnosis(es) is (are) not covered.”
In plain language: The diagnosis code itself is excluded from coverage under your plan.
Common scenarios
- Cosmetic-coded procedure (e.g., panniculectomy)
- Bariatric surgery exclusion
- Fertility exclusion
- TMJ as 'dental' exclusion
What to do next 167
Appeal if the diagnosis represents an essential health benefit (mental health under MHPAEA, women's preventive under ACA, etc.). Cross-reference your plan's exclusion list — sometimes 'cosmetic' is interpreted overly broadly.
DenialHelp helps organize a source-linked draft from the denial notice and confirmed case facts. The patient and treating clinician must verify the governing review rule, current payer policy, clinical sources, attachments, destination, and deadline.
CARC 167 group codes explained
On the 835 ERA, CARC 167 appears alongside a group code that signals who is financially responsible for the adjustment. CO (Contractual Obligation) — Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.
Frequently asked questions
What does CARC 167 mean?
This (these) diagnosis(es) is (are) not covered. In plain language: The diagnosis code itself is excluded from coverage under your plan.
Is CARC 167 appealable?
Yes — CARC 167 is one of the codes that commonly supports an appeal. Appeal if the diagnosis represents an essential health benefit (mental health under MHPAEA, women's preventive under ACA, etc.). Cross-reference your plan's exclusion list — sometimes 'cosmetic' is interpreted overly broadly.
Which group code does CARC 167 appear under?
CARC 167 most often appears under: CO (Contractual Obligation) — Contractual write-off. The provider agreed to the rate. Patient does NOT owe this amount.
When does CARC 167 typically appear on a denial?
Common scenarios: Cosmetic-coded procedure (e.g., panniculectomy); Bariatric surgery exclusion; Fertility exclusion; TMJ as 'dental' exclusion.
How do I appeal a CARC 167 denial?
Appeal if the diagnosis represents an essential health benefit (mental health under MHPAEA, women's preventive under ACA, etc.). Cross-reference your plan's exclusion list — sometimes 'cosmetic' is interpreted overly broadly.
Related appeal verticals
- Bariatric surgery — RYGB, sleeve, duodenal switch, SADI-S, revision, ESGRoux-en-Y gastric bypass, sleeve gastrectomy, BPD/DS, SADI-S, revision bariatric surgery, endoscopic sleeve gastroplasty
- Fertility & IVFIVF, IUI, fertility preservation, PGT, donor cycles
- Mental health & behavioral healthInpatient psych, residential, PHP/IOP, therapy, TMS, Spravato
- Dental — medical necessity, oral surgery, TMJ, cleft palateAdult ortho, implants, oral surgery, TMJ, pre-radiation/transplant clearance
Sources
Appeal a CARC 167 denial
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