CARC 204: This service/equipment/drug is not covered under the patient's current benefit plan
The specific service, device, or drug isn't included in your current plan's covered benefits.
What this means for your claim
Benefit plans vary widely. A service covered under one plan tier or employer may not be covered under another. This is different from a medical necessity denial — the issue is the benefit design itself.
What to do next
- 1
Review your plan's Schedule of Benefits or formulary to confirm the exclusion.
- 2
If you believe the service should be covered, request the specific exclusion language in writing.
- 3
Ask your provider if an alternative covered service could achieve the same outcome.
- 4
If no alternative exists and coverage is essential, contact your HR benefits administrator about plan options.
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