What does CARC 49 mean?

CARC 49 means the service is considered routine, preventive, or screening and is not covered under the patient's plan. The claim is denied as a non-covered service.

Can I appeal a CARC 49 denial?

Usually no, if the service was correctly coded as preventive and the plan doesn't cover it. But if the visit addressed a medical problem, you may be able to recode and resubmit as a problem-focused visit.

Can I bill the patient for a CARC 49 denial?

Yes, if the patient signed an ABN (Advance Beneficiary Notice) or your financial policy covers non-covered preventive services. Always confirm before billing.

CARC 49: Routine or Preventive Service Not Covered

Official CMS Definition

"This is a non-covered service because it is a routine/preventive exam or a diagnostic/screening procedure done in conjunction with a routine/preventive exam."

Group Code: CO, PI, or PR Category: Non-Covered Service Risk Level: High Appealable: Rarely (see below)

What CARC 49 Actually Means

Claim Adjustment Reason Code (CARC) 49 is a non-coverage denial specific to routine and preventive services. The payer is telling you either: (1) the plan does not cover routine/preventive exams, or (2) a diagnostic or screening service was billed alongside a routine exam in a way that caused it to be bundled into the non-covered visit.

The second scenario is far more common, and far more recoverable. Understanding which situation you're in determines everything about what you do next.

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