CARC 198 Denial Appeal

Authorization exceeded (sessions beyond the approved limit)

Precertification/notification/authorization/pre-treatment exceeded.

The winning argument

The denied sessions are the continuation of an already-authorized, medically necessary course of treatment. When a plan has approved an ongoing course of treatment for a set number of visits, cutting coverage off mid-course is an adverse benefit determination on a concurrent-care claim: for ERISA-governed plans, 29 CFR 2560.503-1(f)(2)(ii) requires notice sufficiently in advance of any reduction or termination to allow the claimant to appeal and obtain a determination before benefits stop. An 'authorization exceeded' adjustment that silently terminates an approved course of psychotherapy does not satisfy that standard.

• Visit limits are quantitative treatment limitations and prior-authorization/concurrent review is a non-quantitative treatment limitation; under MHPAEA, both must be no more restrictive — and applied no more stringently — to mental health benefits than to comparable medical/surgical benefits in the same classification.
• If a valid authorization in fact covered the denied dates or units (a renewal was issued, or the auth number was omitted or misapplied on the claim), the denial is an administrative error and the claim should be reprocessed against the correct authorization.
• The claimant is entitled, upon request and free of charge, to copies of all documents, records, and other information relevant to the determination — including the utilization-review/concurrent-review records and the criteria used to refuse continued authorization (29 CFR 2560.503-1(h)(2)(iii)).
• Where reauthorization was delayed or the lapse was outside the provider's control, retroactive authorization of the interim sessions is warranted given documented medical necessity and the clinical risk of interrupting an active course of treatment; payers routinely accept appeals of 198 denials with supporting documentation.

Sample appeal letter body

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We are appealing the denial of psychotherapy services for {{patient_reference}}, denied under CARC 198 (precertification/notification/authorization/pre-treatment exceeded). The sessions at issue ({{cpt_code}}, dates of service {{dates_of_service}}) are part of an ongoing, previously authorized course of treatment: authorization {{authorization_number}} approved {{authorized_session_count}} sessions, and the clinical record documents that continued treatment remains medically necessary — {{clinical_justification_summary}}. Where a plan has approved an ongoing course of treatment for a specified number of visits, any reduction or termination of that course before its end constitutes an adverse benefit determination, and the plan must provide notice sufficiently in advance to allow an appeal to be decided before benefits are reduced or terminated (29 C.F.R. § 2560.503-1(f)(2)(ii)); in this case, {{advance_notice_status}}. We further note that visit limits and authorization-based medical management applied to outpatient mental health services must be no more restrictive, and applied no more stringently, than those applied to comparable medical/surgical benefits under the Mental Health Parity and Addiction Equity Act. We therefore request authorization of the sessions at issue and reprocessing of this claim, and we request, under 29 C.F.R. § 2560.503-1(h)(2)(iii), free copies of all documents, records, and criteria relied upon in this determination, including the concurrent-review records and the authorization history on file.