Denial Code 167: What It Means and How to Appeal
47% of these denials are overturned on appeal (n=56,180)
If you are looking up code 167, you are holding a denial. Denials of this type are overturned about 47% of the time on appeal (n=56,180, external-review records, 2026). Appeal before the deadline.
Denial code 167 means: The diagnosis is not covered.
Why it happens: Diagnosis or coverage-policy mismatch, or insufficient clinical support.
Is it appealable? Yes. Denials of this type are overturned about 47% of the time on appeal (n=56,180, external-review records, 2026).
What to send: the missing element for this code, a short appeal letter citing the plan's claims-procedure rules, and any clinical support.
Note: code 167 may appear on your remittance with a group-code prefix such as PR-167 (patient responsibility) or CO-167 (contractual obligation). The denial reason is the same.
Expert analysis: how this denial is overturned
A medical necessity denial means the plan agrees the service exists and is covered in principle but decided that, in your specific case, it was not clinically warranted. In practice the plan applied an internal coverage guideline and concluded your records did not meet it. For employer and ACA plans, the appeal is governed by 29 CFR 2560.503-1(h)(1), which guarantees a full and fair review, and by 29 CFR 2560.503-1(g)(1)(v), which entitles you to the exact rule, guideline, or criterion the plan used. Demand that criterion first, then rebut it point by point with chart notes, failed prior treatments, and a physician letter mapping your findings to each element. You generally have at least 180 days to appeal (29 CFR 2560.503-1(h)(3)(i)). If the internal appeal fails, medical-judgment denials qualify for independent external review under 45 CFR 147.136(d)(1)(i)(A). Honest odds: Apellica overturns 47% of appealed medical-necessity denials (n=56,180).
Sources: 29 CFR 2560.503-1 (ERISA claims procedure), 45 CFR 147.136 (ACA internal and external review), and the X12 Claim Adjustment Reason Code standard.
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Appeal my code 167 denialFrequently asked questions
- What does denial code 167 mean?
- The diagnosis is not covered.
- Is denial code 167 appealable?
- Yes. Denials of this type are overturned about 47% of the time on appeal (n=56,180, external-review records, 2026).
- What should I send to appeal a code 167 denial?
- Supply the missing element for this code, a short appeal letter citing the plan's claims-procedure rules, and any clinical support. Apellica prepares and files this for you.