CO-55
Procedure/treatment/drug deemed experimental/investigational by the payer
What This Code Means
The payer classifies this treatment as experimental or investigational and therefore not covered.
Common Causes
- Newer treatment/drug not yet added to payer's covered services list
- Off-label use of an approved drug
How to Resolve or Appeal
- Review the payer's medical policy on the specific treatment
- Submit clinical literature/documentation supporting standard-of-care use if applicable
- Discuss patient financial responsibility in advance for known experimental treatments
More Denial Codes to Check
Educational reference only — not medical or legal advice. Always confirm code usage and appeal rights with the specific payer.