CARC 167 appeal letter template — Diagnosis Not Covered

CARC 167 means the payer determined that the diagnosis code(s) submitted on the claim are not covered under the patient's plan or for the billed service; this template helps dispute that determination when the diagnosis is coded correctly and clinically supported.

When to appeal vs. correct & resubmit

Appeal when the diagnosis code billed is accurate, clinically supported by documentation, and you believe it should be covered under the plan's benefit terms or was linked to a covered service. If the diagnosis code was entered incorrectly, outdated, or does not match the documentation, correct the code and resubmit the claim instead of appealing.

Appeal letter template

Copy the template, replace every [bracketed] field with your details, and keep only the paragraph that fits your situation.

[Date]

[Payer Name]
Appeals Department
[Payer Address]

Re: Appeal of Claim Denial — CARC 167 (Diagnosis Not Covered)
Patient Name: [Patient Name]
Member ID: [Member ID]
Claim #: [Claim #]
Date(s) of Service: [DOS]
Billed CPT/HCPCS: [CPT/HCPCS]
Rendering Provider: [Provider Name, NPI]

Dear Appeals Reviewer,

This letter serves as a formal appeal of the above-referenced claim, which was denied under CARC 167, indicating that the diagnosis code(s) submitted are not covered. We respectfully request reconsideration of this determination for the following reasons:

1. The diagnosis code(s) submitted accurately reflect the patient's documented clinical condition at the time of service, as supported by the enclosed medical records.
2. The diagnosis is directly relevant to and supports the medical necessity of the billed service(s) [CPT/HCPCS].
3. [Describe any additional clinical context, coding clarification, or plan benefit information supporting coverage of this diagnosis — e.g., corrected or more specific ICD-10 code, clinical notes, or applicable plan documentation].

We ask that [Payer Name] re-review this claim in light of the enclosed documentation and reconsider the denial. If any additional information is needed to complete this review, please contact our office at [Phone] or [Email].

Thank you for your prompt attention to this matter.

Sincerely,
[Provider Name, NPI]
[Practice Name]
[Phone]
[Email]

What to attach

• Copy of original claim and EOB/ERA showing CARC 167 denial
• Relevant medical records/clinical documentation supporting the diagnosis
• Corrected or clarified diagnosis coding documentation, if applicable
• Plan benefit summary or coverage policy excerpt, if available
• Any prior correspondence with the payer regarding this claim

Frequently asked questions

More free billing tools: all appeal letters · denial codes · NCCI edits · Medicare fees

This template is for informational purposes only and does not constitute legal, billing, or coding advice. It is a general framework to be customized based on the specific claim and payer requirements. Submitting an appeal does not guarantee a reversal of the denial or any particular outcome.