Appealing a Medicare (generic) CO-167 Denial
A Medicare (generic) CO-167 denial (diagnosis not covered) is one of the most common claim rejections behavioral health therapists face. This guide explains exactly what caused the denial and the most effective appeal strategy for behavioral health practices.
What this denial means
The payer is saying the diagnosis code you submitted is not covered under the patient's plan. In behavioral health, this often surfaces as an exclusion for certain mental health diagnoses (e.g. adjustment disorder, V-codes, or substance use) that would not be excluded if they were medical diagnoses.
MHPAEA Mental Health Parity Argument
Selectively excluding mental health diagnoses that would be covered if they were medical diagnoses is a non-quantitative treatment limitation (NQTL) under MHPAEA — the payer cannot exclude a behavioral diagnosis without a comparable exclusion for similar medical diagnoses. Demand the CAA 2021 § 203 NQTL comparative analysis in writing; that statutory disclosure duty applies regardless of the 2025 federal non-enforcement of the 2024 Final Rule.
Request Medicare (generic)'s written Non-Quantitative Treatment Limitation (NQTL) comparative analysis. They are required to provide it under the MHPAEA Enforcement Final Rule (2024).
Your appeal strategy
Review the plan's covered diagnoses list and compare the mental health exclusions against any exclusions applied to analogous medical diagnoses. If the exclusion is diagnosis-specific for mental health only, invoke MHPAEA: excluding a mental health diagnosis that would be covered if it were a medical diagnosis violates parity. Also verify whether the ACA essential health benefit (EHB) mandate covers this diagnosis.
What Medicare (generic) requires
60 calendar days (Level-1 appeal)
180 days from Level-1 denial
Traditional Medicare (Parts A/B) follows the five-level appeals process: Redetermination → Reconsideration (QIC) → ALJ → Medicare Appeals Council → Federal Court. Medicare Advantage plans (Part C) must provide the same five-level process but Part C rules differ (42 CFR § 422.560+). MHPAEA applies to MA plans under 42 U.S.C. § 1395w-22(j).
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How long does Medicare (generic) have to respond to a CO-167 appeal?
Under federal regulations and most state prompt-payment laws, Medicare (generic) must respond to a Level-1 internal appeal within 60 calendar days. If you receive an adverse determination, you typically have 180 calendar days from the date of the Level-1 denial to request external review. Send the appeal via certified mail or through the payer's portal and keep documentation of the submission date.
Does MHPAEA apply to CO-167 denials?
Yes. Selectively excluding mental health diagnoses that would be covered if they were medical diagnoses is a non-quantitative treatment limitation (NQTL) under MHPAEA — the payer cannot exclude a behavioral diagnosis without a comparable exclusion for similar medical diagnoses. Demand the CAA 2021 § 203 NQTL comparative analysis in writing; that statutory disclosure duty applies regardless of the 2025 federal non-enforcement of the 2024 Final Rule. When filing a CO-167 appeal against Medicare (generic), request their written comparative analysis for mental health vs. medical/surgical benefits under 29 CFR § 2590.712. Traditional Medicare (Parts A/B) follows the five-level appeals process: Redetermination → Reconsideration (QIC) → ALJ → Medicare Appeals Council → Federal Court. Medicare Advantage plans (Part C) must provide the same five-level process but Part C rules differ (42 CFR § 422.560+). MHPAEA applies to MA plans under 42 U.S.C. § 1395w-22(j).
Can I appeal a CO-167 denial more than once?
Yes. Most payers, including Medicare (generic), allow at least two levels of internal appeal (Level-1 and Level-2 or "expedited" review). After exhausting internal appeals, you have the right to request an Independent Medical Review (IMR) or external review through your state insurance commissioner. Keep copies of every appeal, submission confirmation, and payer response.
What documentation do I need to appeal a CO-167 denial from Medicare (generic)?
At minimum: the original Explanation of Benefits (EOB) or Remittance Advice (RA) showing the CO-167 denial, the original claim details (CPT code, date of service, NPI, charge amount), and any clinical documentation supporting medical necessity. Because this code has parity implications, also include a written request for Medicare (generic)'s NQTL comparative analysis under MHPAEA. Submit everything in one packet with a cover letter citing the specific denial code, the date of service, and the claim number.