Denied as experimental or investigational
The plan says the treatment isn't proven for your condition. You answer with evidence: guidelines, studies and FDA status.
Official meaning (X12 code 55): Procedure/treatment/drug is deemed experimental/investigational by the payer.
Who pays
CO-55. 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.
PR-55. Patient responsibility: the plan says this part is yours to pay (deductible, copay, coinsurance, or a non-covered service).
What to do
- Ask for the plan's policy on this treatment.
- Ask your doctor for a letter citing guidelines and peer-reviewed studies.
- Appeal, then request external review: these denials are eligible.
If you appeal
Answer with peer-reviewed studies, specialty society guidelines and FDA approval status. Your doctor's letter should explain why this is accepted practice for your condition.
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
Averages across all denials; not a prediction for yours.
Appeal this denial
Upload your denial. We draft the appeal around this code, you approve it, and we fax it to your plan and mail a certified copy. Free check first, then $59.
General information, not legal or medical advice. Owed is a document-preparation and sending service, not a law firm.