Procedure/treatment/drug is deemed experimental/investigational by the payer. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
Group code
CO, PI or PR
Category
Non-Covered Service
Risk level
Medium
Appealable
No
Common RARC pairings
RARCs (Remittance Advice Remark Codes) provide the specific reason detail alongside CARC 55 on the 835 electronic remittance. These are the RARCs seen most often with this CARC.
| RARC | Meaning |
|---|---|
| M49 | Missing/incomplete/invalid value code(s) or amount(s). |
| N10 | Adjustment based on the findings of a review organization/professional consult/manual adjudication/medical advisor/dental advisor/peer review. |
| N111 | No appeal right except duplicate claim/service issue. This service was included in a claim that has been previously billed and adjudicated. |
| N115 | This decision was based on a Local Coverage Determination (LCD). An LCD provides a guide to assist in determining whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd, or if you do not have web access, you may contact the contractor to request a copy of the LCD. |
| N623 | Not covered when deemed unscientific/unproven/outmoded/experimental/excessive/inappropriate. |
| N789 | Clinical Trial is not a covered benefit. |
| N794 | Payment adjusted based on type of technology used. |
See the full resolution workflow for CARC 55
Members of the EDI-Code Intelligence Lab get the step-by-step rework path, appeal language, root-cause drivers, and prevention checklist for every CARC and RARC pairing, plus payer-specific quirks.
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