CARC 55CO · Contractual Obligation
The payer classifies this procedure, treatment, or drug as experimental or investigational and therefore doesn't cover it.
- Common causes
- The treatment lacks FDA approval for this indication, or isn't yet supported by the payer's evidence-based coverage policies.
- Suggested fix
- Review the payer's medical policy for experimental/investigational criteria; if a signed waiver (like an ABN) exists, the patient may be billed, otherwise appeal with clinical literature support.
Related Contractual Obligation codes
107This claim depends on another related claim or service being referenced, but that link wasn't provided.11The diagnosis code doesn't support medical necessity for the procedure billed, based on the payer's coverage edits.13The claim shows a date of service after the patient's recorded date of death.146The diagnosis code billed wasn't a valid, active code as of the date of service.150The documentation submitted doesn't justify the complexity or level of the service billed, commonly seen with evaluation and management visit levels.16The claim is missing required information or contains a billing error that prevented the payer from processing it.170This payer doesn't reimburse this specific provider type for this service.171This payer doesn't cover this service when it's billed by this provider type in this particular facility setting.
Frequently asked questions
What does CARC 55 mean?
The payer classifies this procedure, treatment, or drug as experimental or investigational and therefore doesn't cover it.
How do I resolve CARC 55?
Review the payer's medical policy for experimental/investigational criteria; if a signed waiver (like an ABN) exists, the patient may be billed, otherwise appeal with clinical literature support.
Why does CARC 55 happen?
The treatment lacks FDA approval for this indication, or isn't yet supported by the payer's evidence-based coverage policies.
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.