CO-272 Denial Code: Coverage Guidelines Not Met

The CO-272 denial code means the service did not meet the payer's coverage or program guidelines — the medical-policy criteria, documentation, or program rules the plan requires before it pays. It carries the Contractual Obligation group, so the amount is a provider write-off unless you overturn it. CO-272 is a policy denial, which makes it one of the more appealable codes whenever your documentation actually satisfies the criteria the payer is citing.

What is the CO-272 denial code? CO-272 is a Claim Adjustment Reason Code (CARC) indicating the service did not meet the payer's coverage or program guidelines — its medical-policy, documentation, or program criteria — with the charge grouped under Contractual Obligation.

In Practice

CO-272 is frustrating precisely because it is vague on the remittance, but that vagueness is also the opening. Every CO-272 points to a specific coverage policy — a medical-policy bulletin, an LCD, or a program rule with named criteria — and the payer is obligated to identify it, usually in the 835 policy-identification segment or an accompanying remark code. The appeal that works is not a general letter about medical necessity; it is a point-by-point demonstration that the chart already meets each criterion the cited policy lists. Find the policy first, map your documentation to it, and the denial often reverses without new clinical work — the evidence was there, just never aligned to the rule.

What CO-272 Means

CO-272 indicates the claim was adjudicated against the payer's coverage or program guidelines and did not meet them. Those guidelines can be a medical-necessity policy, a documentation requirement, a frequency or step-therapy rule, or a program eligibility condition. It is broader than a flat non-covered determination — the service may be covered in principle but failed a specific criterion the policy sets for paying it.

Why CO-272 Happens

The documentation did not establish a criterion the payer's medical policy requires.
A prior-authorization or step-therapy condition in the policy was not satisfied.
The service exceeded a frequency or coverage limit defined in the program guidelines.
The diagnosis or clinical detail submitted did not match the policy's coverage criteria.

Finding the Policy the Payer Cited

The first move on a CO-272 is identifying the exact guideline. Check the remittance for a referenced policy or bulletin number, the accompanying RARC remark code, and the 835 healthcare policy identification segment, which often names the rule. Pull that policy and read its coverage criteria verbatim; the denial only tells you the guidelines were not met, while the policy tells you which criterion failed and what evidence would satisfy it.

How to Fix and Appeal a CO-272

Locate the specific coverage or program policy the payer cited on the remittance and read its criteria.
Map the patient's chart against each criterion to find what the payer says is missing.
Assemble the documentation that demonstrates the criteria are met, or correct the claim if the issue was coding.
File the appeal with the policy criteria and matching documentation, or draft it with the appeal generator.

Related Codes

CO-272 sits among the coverage and necessity codes. CO-50 is a flat lack-of-medical-necessity determination, CO-96 is a non-covered charge, and CO-222 is a contracted-units cap. Browse the full set under denial codes.

Frequently Asked Questions

What does CO-272 mean?

CO-272 means the service did not meet the payer's coverage or program guidelines — the medical-policy, documentation, or program criteria required before the plan pays. The service may be covered in principle but failed a specific criterion the policy sets.

How do I find which guideline CO-272 refers to?

Check the remittance for a referenced policy or bulletin number, the RARC remark code, and the 835 policy identification segment, which often names the rule. Pull that policy to see the exact coverage criteria and which one was not met.

Is CO-272 worth appealing?

Often yes. Because CO-272 is a policy denial, it reverses when you show the chart meets the cited criteria. Map your documentation to each criterion in the named policy and appeal with that evidence.

How is CO-272 different from CO-50?

CO-50 is a flat determination that the service was not medically necessary. CO-272 is broader — the service may be covered but did not meet a specific coverage or program guideline, such as a documentation, frequency, or authorization criterion.

Informational only — not legal, medical, or billing advice. Always verify against your current payer policy.

Fix CO-272 denials automatically

Undeny maps your documentation to the cited coverage policy and drafts the appeal. Generate an appeal · Browse denial codes