CARC 50PR · Patient Responsibility

The payer determined the service wasn't medically necessary based on the diagnosis and documentation submitted.

Common causes
The diagnosis code doesn't support the medical necessity criteria the payer applies to this service, or documentation didn't demonstrate necessity.
Suggested fix
Review payer medical policy for this service, submit supporting clinical documentation via appeal if necessity can be shown, and confirm whether an Advance Beneficiary Notice was signed before billing the patient.

Related Patient Responsibility codes

1The billed amount was applied to the patient's plan deductible instead of being paid by the payer.119The patient has used up the maximum benefit allowed for this service within the applicable time period, such as an annual visit limit.167The specific diagnosis code(s) on this claim aren't covered under the patient's plan.177The patient doesn't currently meet the plan's eligibility criteria for this benefit.187This amount was or should be paid from the patient's consumer-directed spending account, such as an HSA or FSA, rather than by the payer.2This portion of the claim represents the patient's coinsurance share, the percentage of the allowed amount they are responsible for under their plan.200The service date falls within a period when the patient's coverage had lapsed.201The patient is responsible for this amount under a legal set-aside arrangement, commonly seen in workers' compensation Medicare Set-Aside cases, rather than the payer.

Frequently asked questions

What does CARC 50 mean?

The payer determined the service wasn't medically necessary based on the diagnosis and documentation submitted.

How do I resolve CARC 50?

Review payer medical policy for this service, submit supporting clinical documentation via appeal if necessity can be shown, and confirm whether an Advance Beneficiary Notice was signed before billing the patient.

Why does CARC 50 happen?

The diagnosis code doesn't support the medical necessity criteria the payer applies to this service, or documentation didn't demonstrate necessity.

CARC codes maintained by X12 (x12.org). Descriptions on this site are original reference interpretations. Always verify codes with authoritative sources before making billing decisions.