CARC 204 appeal letter template — Service/Equipment/Drug Not Covered Under Plan

[Date]

[Payer Name]
Appeals Department
[Payer Address]

Re: Appeal of Denial – CARC 204 (Not Covered Under Patient's Current Benefit Plan)
Patient Name: [Patient Name]
Member ID: [Member ID]
Claim #: [Claim #]
Date(s) of Service: [DOS]
Billed CPT/HCPCS: [CPT/HCPCS]
Rendering/Billing Provider: [Provider Name, NPI]

Dear Appeals Reviewer,

We are writing to formally appeal the denial of the above-referenced claim, which was denied under CARC 204 ("This service/equipment/drug is not covered under the patient's current benefit plan"). We respectfully request a review of this determination, as we believe the billed service/equipment/drug may in fact be a covered benefit under the patient's plan.

Basis for appeal:
- [Describe why the service should be covered, e.g., reference to Summary of Plan Description/benefit booklet language, a prior authorization granted for the same service, or a prior paid claim for the same benefit.]
- [Note if the CPT/HCPCS code was applied correctly and corresponds to a covered benefit category.]
- [Include any communication from the payer or plan documents indicating coverage.]

Enclosed please find supporting documentation, including the Explanation of Benefits/Electronic Remittance Advice, relevant medical records, and any plan benefit documentation supporting coverage of this service.

We ask that the claim be reprocessed for payment consistent with the patient's benefit plan terms. Please contact our office with any questions or if additional information is required to complete this review.

If an authorization was obtained prior to service, it is referenced here: Authorization #: [Authorization #].

Thank you for your attention to this matter.

Sincerely,

[Provider Name, NPI]
[Practice/Facility Name]
[Phone]
[Email]