CO-151

Denied for too many services

The plan thinks you had the service more often than needed. Records showing why each one was necessary can overturn it.

Official meaning (X12 code 151): Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.

Who pays

CO-151. Contractual obligation: the provider's contract with your plan makes this the provider's write-off. An in-network provider generally can't bill you for a CO amount.

What to do

Ask the provider for records supporting each date of service.
Appeal with a letter explaining the frequency.

If you appeal

These denials are decided on paperwork, so better paperwork can change them. Answer by showing the care meets the plan's own criteria: a letter of medical necessity from your doctor, the relevant chart notes, and what you already tried that didn't work. Ask the plan for the exact clinical criteria it used, and for a reviewer in the same specialty.

What the appeal asks for: Overturn the medical-necessity denial. Please provide, free of charge, the clinical criteria, guidelines and reviewer credentials relied on, and have the appeal reviewed by a physician in the same or a similar specialty who was not involved in the initial decision.

Basis: 29 CFR §2560.503-1(h)(2)(iii) and (h)(3)(iii)

Deadlines for the first appeal

employer plan: 180 days from the notice
ACA Marketplace plan: 180 days from the notice
Medicare Advantage plan: 65 days from the notice
Original Medicare: 120 days from the notice
Medicaid: 60 days from the notice

The date printed on your notice controls. Urgent care can be appealed on an expedited (72-hour) basis.

What the data show

11.5%Only 11.5% of denied Medicare Advantage prior authorization requests were appealed in 2024. KFF, 2024 data

80.7%80.7% of appealed Medicare Advantage prior authorization denials were partially or fully overturned in 2024. KFF, 2024 data

<1% (262,982 appeals)Fewer than 1% of denied in-network marketplace claims were appealed in 2024 (at least 262,982 appeals). KFF, 2024 data

66% upheldInsurers upheld 66% of denials on internal appeal in 2024 (165,863 denials). KFF, 2024 data

5%Only 5% of in-network marketplace denials were based on medical necessity. KFF, 2024 data

Averages across all denials; not a prediction for yours.

Appeal this denial

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General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.