CARC Code
56
Treatment Not Proven Effective
The insurance company has determined that the procedure or treatment provided has not been proven to be effective based on their medical policy standards. This is a medical necessity denial.
medical necessityHow to resolve this denial
Submit appeal with evidence-based medical literature supporting treatment
- 1
Obtain the complete medical record documenting the clinical need for the service
- 2
Review the payer's LCD/NCD or coverage policy for the billed procedure
- 3
Prepare a Letter of Medical Necessity from the treating physician
- 4
Submit a formal appeal with clinical records, the letter, and peer-reviewed literature
- 5
Track the appeal and follow up within 30 days
▶✓ 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-56 — stats, related codes, appeal template
35%
Recovery Rate
21-45 days
Avg. Resolution
Hard
Difficulty
Rare
Frequency
Payer-Specific Notes
How major payers handle CARC 56 by specialty.
Blue Cross Blue Shield
BCBS requires appeal submission within 180 days for most plans.
Appeal Letter Template
Generic appeal template for CARC 56 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 56 indicating: "Procedure/treatment has not been deemed proven effective by the payer.." 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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