CARC 96 Denial Appeal
Non-covered charge
Non-covered charge(s).
Why CARC 96 hits behavioral-health claims
Evidence-based BH treatments (psychological testing, IOP, TMS, family therapy) are frequently excluded by employer plans as 'experimental' or 'educational' even when they are standard, medically necessary care.
The winning argument
Categorically excluding a specific, evidence-based behavioral-health service while covering analogous intensive/specialized medical/surgical care is a scope-of-service NQTL subject to strict parity testing.
- The treatment is recognized standard-of-care for the diagnosis under current guidelines.
- The exclusion is mislabeled 'experimental' despite an established evidence base.
Public sources you can cite
Every argument traces to a verified public source — no invented citations.
X12 — Claim Adjustment Reason Codes (official)
Supports: Official wording of CARC 96
Federal Register — 2024 MHPAEA Final Rule
Supports: Scope-of-service exclusions can function as NQTLs subject to parity testing
American Psychiatric Association — Parity
Supports: Challenging sweeping BH service exclusions as parity violations
Sample appeal letter body
Replace the {{placeholders}} with your own information before sending.
We are appealing the CARC 96 denial classifying {{cpt_code}} ({{service_description}}) as a non-covered charge for {{patient_reference}}. This treatment is recognized, evidence-based standard-of-care for {{diagnosis}}. Categorically excluding this behavioral-health service, while analogous medically necessary interventions are covered for medical/surgical conditions, operates as a non-quantitative treatment limitation under the Mental Health Parity and Addiction Equity Act. We request the plan's comparative analysis demonstrating that the criteria used to exclude this service are applied no more stringently to behavioral-health benefits than to medical/surgical benefits in the same classification.You'll need to supply: patient_reference, cpt_code, service_description, diagnosis
What this argument cannot ground
Honest gaps — no fabricated sources.
- State-specific coverage mandates vary; clinician should add their state statute if applicable.
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