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Remittance advice remark code

N115: Decision based on a Local Coverage Determination

N115 means: 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. A published coverage policy for your region decided this, and that policy states exactly what would have been covered.

N115 is a remark code, not a reason code

It explains or adds detail to a decision. It does not carry a group code, and it can never on its own make a balance the patient’s responsibility. The claim adjustment reason code on the same remittance line is what actually decides the outcome — read that first, then read this for the detail.

CARC — claim adjustment reason code. What was adjusted, and under which group code.
RARC — remittance advice remark code, like this one. Explanatory only. No group code, no patient responsibility.
Never move a balance to the patient on the strength of a remark code. Find the reason code and read its group code.

What causes it

Diagnosis billed not on the policy’s covered list
Frequency or documentation requirements in the policy not met
Service considered not reasonable and necessary for the indication under that policy

How to work it

Find and read the actual policy. It lists the covered diagnoses and the documentation required, which makes this one of the most answerable denials there is.
Where the record supports a covered indication that was not billed, correct the coding to match the record — never to match the policy.
Where the documentation requirements were met, appeal citing the policy’s own criteria point by point.
Where they were not met, an advance beneficiary notice before the service is the mechanism, not an appeal afterwards.

How to stop it recurring

For services covered by a determination in your region, check the policy at scheduling. The requirements are published and specific, which is unusual and useful.

Who does this work

A medical coding seat at $2,500 per seat per month works this queue full time, during your business hours, inside your own system. Every call is logged with the payer reference number and the outcome, and every Friday you get it in writing.

What that seat does →

Codes worked the same way

N115 is appealed with clinical documentation. 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-50 — Not deemed medically necessary
CO-151 — Too many services billed
CO-96 — Non-covered charges
CO-170 — Provider type not paid
CO-234 — Not paid separately
CO-236 — Modifier combination not allowed

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.

Pain Management
RFA denied because the chart does not carry percent relief and duration from both diagnostic blocks
Orthopedics
Implant and hardware charges denied for missing invoice documentation
Behavioral Health
Time-based psychotherapy codes not supported by documented duration
Cardiology
Stress tests denied for medical necessity documentation
Podiatry
At-risk foot care documentation not naming the treating physician for the systemic condition
Physical Therapy
Timed code units not supported by documented treatment minutes

What leaving it costs

Working a denied claim costs $57.23 per denied claim in administrative time. Source. At 100 denials a month — an illustration, not a measurement of your practice — that is $5,723 a month, or $68,676 a year, in labour alone.

The figure that makes it worth spending: about 90% of initially denied claims are eventually paid. Source. The reason a denial sits is almost never that nobody knows how to work it — it is that nobody has the hours.

Questions

What does denial code N115 mean?

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. In plain terms: A published coverage policy for your region decided this, and that policy states exactly what would have been covered.

What causes N115?

Diagnosis billed not on the policy’s covered list. Frequency or documentation requirements in the policy not met. Service considered not reasonable and necessary for the indication under that policy.

How do you fix a N115 denial?

Find and read the actual policy. It lists the covered diagnoses and the documentation required, which makes this one of the most answerable denials there is.. Where the record supports a covered indication that was not billed, correct the coding to match the record — never to match the policy.. Where the documentation requirements were met, appeal citing the policy’s own criteria point by point.. Where they were not met, an advance beneficiary notice before the service is the mechanism, not an appeal afterwards..

Can N115 be prevented?

For services covered by a determination in your region, check the policy at scheduling. The requirements are published and specific, which is unusual and useful.

What about the codes next to N115?

N114 and N116 are separate codes and this site does not yet cover them. The authoritative list is the X12 Remittance Advice Remark Codes at x12.org/codes/remittance-advice-remark-codes; a code is only described here once its official text, causes and fix have been written and checked.

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.

Last updated 2026-09-12. This is operational guidance drawn from payer remittance practice, not legal, coding or reimbursement advice. Payer-specific rules vary and change; confirm against the payer’s own policy before acting on a specific claim.

Written by Ibtesam Asif · Last reviewed 2026-09-12

Code descriptions are the standard published text. Everything after them is operational guidance from our own work, and payer policy governs any individual claim.

Other denial codes

Next step

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