How do I resolve a CO-204 denial?

A Redetermination request may be submitted with all relevant supporting documentation. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal. Review applicable Local Coverage Determination (LCD), LCD Policy Article, and Documentation Checklists prior to submitting request. See full Medicare contractor resolution steps at tryarceum.com.

Can I appeal a CO-204 denial?

CO-204 denials are generally not appealable. Appeals are typically unsuccessful because this is a contractual benefit design issue, not a claim processing error or medical necessity determination.

CARC Code

204

🔴 Hard Denial

Service Not Covered by Plan

The insurance plan does not include coverage for this particular service, equipment, or medication. This is a benefit limitation, not a medical necessity issue.

contractual

Resolution: 35%Hard difficulty21-45 days avg

How to resolve this denial

Which payer denied this claim?

▶✓ Pre-action checklist — verify before contacting the payer

Review the full remittance advice (ERA/EOB) for additional RARC codes that explain the denial.
Verify the claim was submitted with correct patient eligibility and benefit information.
Check if this denial applies to a specific line item or the entire claim.

▶More about CO-204 — stats, related codes, appeal template

35%

Recovery Rate

21-45 days

Avg. Resolution

Hard

Difficulty

Occasional

Frequency

Payer-Specific Notes

How major payers handle CARC 204 by specialty.

Blue Cross Blue Shield

BCBS requires appeal submission within 180 days for most plans.

Common 835 Combinations

CARC 204 most often appears with these Group Code + RARC combinations on 835 remittances.

PRPR-204The service, equipment, or drug billed is excluded from the patient's specific PRPR-204+N130The service rendered is excluded from the patient's specific benefit plan

Look up any combination →

Appeal Letter Template

Generic appeal template for CARC 204 denials.

We are submitting a formal appeal for claim [CLAIM_NUMBER] for patient [PATIENT_NAME], date of service [DOS]. This claim was denied/adjusted with CARC 204 indicating: "This service/equipment/drug is not covered under the patient's current benefit p." We have reviewed the claim and are providing the attached documentation to support reconsideration. [SUPPORTING_DOCUMENTATION]. Please reconsider payment per the terms of our contract.

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