CO-272: Coverage or program guidelines not met

What causes CO-272?

• Frequency limit exceeded — the service is covered but not this often
• A required prior step not documented, such as a conservative treatment period
• Coverage determination criteria not met for the diagnosis billed
• A required screening interval not yet elapsed

How do you fix a CO-272 denial?

1. Get the specific guideline that was not met from the payer, in writing where the amount justifies it.
2. Check the frequency history — a service delivered elsewhere counts, and the practice usually cannot see it.
3. Where prior conservative treatment exists in the record, appeal with those dates documented.
4. Where the criteria genuinely were not met, the conversation is with the provider about the pathway, not with the payer.

Can CO-272 be prevented?

For services with frequency limits or step requirements, check the history at scheduling. This denial is almost always knowable before the visit.

A denial like this one is the recurring cost that medical billing outsourcing is built to take off your desk — a dedicated seat working the queue instead of it waiting for whoever has a free hour.

Codes worked the same way

CO-272 is taken back to the authorization. So are these, which is why a queue sorted by recovery route moves faster than one sorted by code number — the same person, in the same system, with the same evidence to hand, clears all of them in one pass.

• CO-197 — Prior authorization absent
• CO-198 — Authorization limit exceeded
• CO-288 — Referral absent
• CO-15 — Authorization number missing
• CO-39 — Authorization already refused
• N54 — Claim does not match the authorization

Specialties that name this among their costliest

These are specialties whose own worst denials include one of this kind. The line under each is the denial they name, quoted from their page so you can see what the link is based on.

• Ambulatory Surgery Centers
  Prior authorization obtained for the surgeon but not the facility
• Behavioral Health
  Authorization units exhausted mid-course without renewal
• Urology
  Prior authorization missing for advanced imaging
• Radiology
  Advanced imaging denied for missing prior authorization
• Ophthalmology
  An injection given after the drug authorization lapsed, or under an authorization written for a different agent than the one actually drawn up that day.
• Neurology
  Long-term video EEG authorized as an ambulatory home recording but performed as an admission to the epilepsy monitoring unit, so the facility days sit outside the authorization

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time (source) — before any of it is recovered, and whether or not it ever is.

Payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment (source), so the reason one sits is rarely that nobody knows how to work it. Put your own denial count in.

Questions

Code descriptions are the standard X12 claim adjustment reason and remittance advice remark code text. Payer policies differ, and the payer’s own coverage policy governs any individual claim. This page is working guidance, not legal or clinical advice.