CO-204 — Not covered under the patient’s current benefit plan
Claim-adjustment reason code 204 · typically reported as CO-204 or PR-204
What it means
The plan the patient actually has doesn’t include this item — a benefit-design exclusion rather than a medical-necessity decision.
Why DME claims hit it
- Commercial plans excluding certain DME categories (e.g., some exclude CGM supplies or bathroom equipment)
- MA plan benefit carve-outs differing from Original Medicare
How to fix it
- Verify item-level benefits (not just "has DME benefit") before delivery; offer self-pay with a clear estimate when excluded
Appeal posture
Benefit exclusions rarely overturn; member-level exception requests occasionally succeed on commercial plans.
Related denial codes
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