CARC 204 Denial Appeal

Not covered under current benefit plan

This service/equipment/drug is not covered under the patient's current benefit plan.

The winning argument

Excluding a specific, medically necessary behavioral-health service while covering analogous medical/surgical interventions is a discriminatory NQTL under federal parity law; a state mandate or medical-exception pathway may also require coverage.

• The service may be a state-mandated benefit overriding the plan exclusion.
• The treatment was erroneously classified as experimental despite an evidence base.
• A medical exception applies where covered alternatives have failed.

Sample appeal letter body

Replace the {{placeholders}} with your own information before sending.

We are appealing the denial of {{service_name}} for {{patient_reference}} under CARC 204 (not covered under the current benefit plan). While the plan cites an exclusion, {{service_name}} is the evidence-based standard-of-care for {{patient_diagnosis}}, recognized by {{clinical_guideline_source}}. Denying this behavioral-health intervention while covering analogous medical/surgical rehabilitative care operates as a discriminatory non-quantitative treatment limitation under the Mental Health Parity and Addiction Equity Act. {{state_law_if_applicable}} Based on the attached clinical documentation showing that covered alternatives have failed, we request a medical exception and coverage.