CARC 167: This (these) diagnosis(es) is (are) not covered.

CARC 167 appears on the 835 ERA (Electronic Remittance Advice) that the payer returns after claim adjudication. It explains a reduction, denial, or payment adjustment to your billing team. For your practice, the question is workflow: identify the pattern, route the denial to the right resolution path (rebill, appeal, write-off), and recover what's recoverable without burning RVU time on dead-end fights.

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

Practice workflow for CARC X 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.

ApprovalHelp auto-drafts the appeal letter against the right federal appeal-rights regulation (ACA §2719, ERISA §503, NSA §2799A, 42 CFR 422 Subpart M, or 42 CFR 438 Subpart F) for the patient's plan type, the payer's own coverage policy, and the relevant clinical guideline. Drafts route to the clinician for signature in under five minutes.

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.