CO-167 — Diagnosis not covered
Claim-adjustment reason code 167 · typically reported as CO-167
What it means
The specific diagnosis billed isn’t one the payer covers for this item — close cousin of CO-11/CO-50, keyed to the dx list itself.
Why DME claims hit it
- Dx outside the LCD’s covered list for the item
- Coding to symptoms instead of the qualifying condition
How to fix it
- Match the chart’s documented conditions to the policy’s covered-dx list; query the physician when a covered condition exists but wasn’t coded
Appeal posture
Appeal when the record documents a covered condition; otherwise ABN/private-pay prospectively.
Related denial codes
CO-11 — Diagnosis inconsistent with the procedureCO-50 — Not deemed medically necessaryCO-146 — Diagnosis invalid for the date of service
Looking up an item instead? Browse the HCPCS code library for fee schedule amounts and PA flags.
Turn denials into recovered revenue
MyMedi-AI maps every remit code to its fix, tracks appeal deadlines, and drafts appeal letters with the right documentation checklist.
Start free trial Run a CMS-0057-F readiness check