CARC 49: Non-Covered Routine/Preventive Exam or Related Screening Procedure

What it means

The payer is denying this claim because the service billed is considered routine or preventive, or it's a screening/diagnostic test performed during a routine/preventive visit, and the plan does not cover it under the patient's current benefit terms.

Common causes

Patient's plan excludes routine/preventive services entirely
Service billed does not meet payer-specific criteria for preventive care coverage (e.g., frequency limits exceeded)
Diagnostic test was billed with a routine/preventive diagnosis code instead of a medically necessary one
Preventive benefit has already been used for the benefit period
Screening performed outside the age/frequency guidelines set by the payer
Incorrect coding pairing a screening code with an exam that the payer treats as bundled/non-covered

How to fix it

Review the patient's specific plan documents to confirm whether routine/preventive services are covered and under what conditions
Verify the diagnosis code used; if the visit was not purely preventive, consider whether a more accurate diagnosis reflecting medical necessity applies
Check frequency/age limits for the specific screening or preventive service against payer guidelines
If the service was medically necessary (not purely routine), resubmit with appropriate documentation and diagnosis coding to support medical necessity
Confirm whether the patient has preventive benefits remaining for the current benefit period
Bill the patient according to plan terms if the service is confirmed non-covered, following your payer and state notification requirements

Appeal / resubmit

If you believe the service was medically necessary rather than purely routine/preventive, gather clinical documentation (symptoms, abnormal findings, or risk factors) supporting that it was not a standard preventive screening, and submit an appeal with the corrected diagnosis and supporting notes. Review the payer's preventive services policy to confirm frequency/age criteria were met if applicable.

Related codes

96
50
96
N130

Frequently asked

Does this mean the patient owes the full amount?

It depends on the plan. Many preventive services have patient responsibility terms outlined in the benefit plan; review the plan's Explanation of Benefits (EOB) and coverage policy before billing the patient.

Can this denial be overturned?

It may be reconsidered if documentation shows the service was medically necessary rather than routine, or if coding errors caused the denial. Outcomes vary by payer and plan specifics.

What if the same test is billed again later?

Check the payer's frequency limits for preventive screenings; resubmitting too soon after a prior service may trigger the same denial.

More free billing tools: all denial codes · denial lookup · Medicare fee calculator

This content is for informational purposes only and does not constitute billing or legal advice. Coverage determinations depend on specific payer policies and plan terms.