Procedure/treatment has not been deemed 'proven to be effective' 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
Medical Necessity
Risk level
High
Appealable
Yes
Common RARC pairings
RARCs (Remittance Advice Remark Codes) provide the specific reason detail alongside CARC 56 on the 835 electronic remittance. These are the RARCs seen most often with this CARC.
| RARC | Meaning |
|---|---|
| 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. |
See the full resolution workflow for CARC 56
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.
Open in EDI Lab