RemitBench/Denial codes/CO-272

CO-272 denial code

Code 272 says a rule was not met. It does not say which rule. It is a newer and slightly more specific relative of 96, and like 96 it is useless until you find the remark.

The code list's own wording: Coverage/program guidelines were not met.

Why the payer sent it

• A clinical criterion in the payer's policy was not documented.
• A step therapy or sequencing rule was skipped. That is close to CO-B15.
• A required attachment was not sent, which overlaps with CO-252.
• The service needed prior authorisation under the programme rules. See CO-197.
• The patient did not meet an eligibility condition attached to the programme rather than to the plan.

Remark codes you will see with it

Read the letters in front of the 272

What to do next

1. Get the guideline reference

   Number and version date. Without it you are writing an appeal against something you have not read.

2. Turn the guideline into a checklist and mark your chart against it

   This is the whole job. Most guidelines are four or five conditions. Go through them one at a time and mark which the chart supports.

   If the chart meets them all: your appeal is short and strong. Quote each condition and point at the page that answers it. If it misses one: decide honestly whether it can be documented properly. If not, this is a write-off and chasing it wastes the afternoon.

3. Check whether the real problem is authorisation or an attachment

   Both hide behind this code. Either one has a faster fix than a clinical appeal.

Codes that get mixed up with 272

The pair 272 and 273 is worth learning together. Not met means you missed a condition. Exceeded means you passed a limit. One is answered with documentation and the other usually is not.

Code 272 in dental

Dental carriers use this for their processing policies: the conditions attached to crowns, periodontal therapy, implants and replacements. Those policies are published, and reading the one that applies is nearly always faster than appealing blind.

The common dental guidelines behind a 272

• A crown needing documented tooth loss or decay beyond what a filling can restore.
• Periodontal therapy needing charting and often radiographs that show the disease.
• A replacement needing the age of the existing restoration.
• A build up needing evidence that enough tooth structure was missing.

Charting is the appeal

For most of these the evidence is something the practice already has: the perio chart, the radiograph, the date of the prior restoration. The denial happens because it was not attached, not because it does not exist.

Questions people ask about CO-272

What guideline does CO-272 refer to?

The code never says. It refers to whichever coverage or programme policy the payer applied, and you have to ask for it by name. Payers publish these with numbers and version dates, and an appeal written without reading the guideline is guessing at what it has to overcome.

What is the difference between 272 and 273?

Not met against exceeded. A 272 means a condition attached to the service was not satisfied, which documentation can often fix. A 273 means a limit was passed, which documentation usually cannot.

Related codes

• CO-273 Guidelines exceeded rather than not met.
• CO-96 The general not covered code this one narrows.
• CO-50 Not medically necessary. The judgment version.
• CO-197 Authorisation absent, which hides behind 272 more often than it should.
• CO-252 An attachment is required. The other thing hiding behind this code.

Back to all denial codes