Denial Code CO-167: Diagnosis Not Covered
What Does Code 167 Mean?
This (these) diagnosis(es) is (are) not covered, or are missing or are invalid. The diagnosis code is not payable under the patient's plan.
Group Code CO (Contractual Obligation): The provider has agreed to accept the payer's determination. The patient is generally not responsible for this amount.
Why Does This Happen?
The ICD-10 code is excluded from coverage or is incorrect.
How to Resolve It
- 1Review diagnosis coding for accuracy
- 2Check if an alternative ICD-10 code is covered
- 3Appeal with clinical documentation supporting the diagnosis
- 4If medical necessity, request peer-to-peer review
This Denial Is Often Overturned With a Peer-to-Peer Call
When you receive denial code CO-167, the most effective next step is usually a peer-to-peer (P2P) call with the payer's medical director. During this call, you can present your clinical reasoning directly and often get the denial reversed on the spot.
Our free P2P Call Prep Tool generates a structured script based on your specific case, the payer involved, and the denial reason -- so you walk into the call prepared and confident.