CARC 269 Active

PR-269: Anesthesia Not Covered for This Procedure

TL;DR

The payer denied anesthesia coverage for the billed procedure. If anesthesia was medically necessary beyond what the payer expected, appeal with operative reports, anesthesia records, and a physician letter explaining the clinical need.

Action
Review & Decide
Who Pays
Patient
Appeal
No
Patient Impact
Direct Financial
Disclaimer
This content is for informational purposes only and does not constitute professional billing advice. Always verify information against your payer contracts and current coding guidelines. Consult a certified billing specialist for specific claim issues.

What Does PR-269 Mean?

CARC 269 indicates the payer determined that anesthesia is not a covered benefit for the specific procedure performed. Many payers maintain policies defining which procedures qualify for separate anesthesia reimbursement. Minor procedures that can typically be performed under local anesthesia may not include coverage for general or monitored anesthesia care.

The denial may also stem from missing pre-authorization, incorrect anesthesia coding, insufficient documentation of medical necessity, or plan-specific restrictions on anesthesia for certain procedure categories. In some cases, the anesthesia service itself was appropriate, but the billing did not adequately communicate why it was needed.

When the anesthesia was genuinely medically necessary — for example, due to the patient's anxiety level, medical condition, age, or the complexity of the procedure — the path forward is a clinical appeal with documentation supporting the medical necessity.

How to Resolve

Review the payer's anesthesia coverage policy for the procedure, verify coding accuracy, and appeal with clinical documentation if anesthesia was medically necessary.

  1. Review anesthesia documentation Examine the anesthesia records and operative report for documentation supporting the medical necessity of anesthesia for this procedure.
  2. Verify coding accuracy Confirm the anesthesia codes, procedure codes, and modifiers are correct and properly matched.
  3. Check payer anesthesia coverage policy Review the payer's specific policy on anesthesia coverage for this procedure code.
  4. File a clinical appeal Submit an appeal with the operative report, anesthesia records, and a physician letter explaining why anesthesia was required for this patient and procedure.
  5. Contact payer for clarification If the coverage policy is unclear, contact the payer to understand the specific coverage requirements for anesthesia.
  6. Request peer-to-peer review If the initial appeal is denied, request a peer-to-peer review to discuss the clinical necessity directly.
Do Not Appeal This Code

Anesthesia Not Covered for This Procedure reflects a service that falls outside covered benefits, with the patient held responsible. Coverage decisions per plan terms generally aren't appealable in the traditional sense — the appropriate next step is verifying the patient was informed (ABN where applicable) and billing the patient if the determination is correct.

Also Filed As

The same CARC 269 may appear with different Group Codes:

CO-269 OA-269

Related Denial Codes

PR-26 — Expenses Incurred Prior to Coverage PR-27 — Expenses Incurred After Coverage Terminated PR-32 — Patient Not Eligible Dependent PR-33 — Insured Has No Dependent Coverage PR-34 — No Coverage for Newborns

Sources

  1. https://www.mdclarity.com/denial-code/269
  2. https://resdac.org/sites/datadocumentation.resdac.org/files/Adjustment%20Reason%20Code%20Code%20Table%20(TAF%20Claims).txt
  3. https://x12.org/codes/claim-adjustment-reason-codes
  4. Codes maintained by X12. Visit x12.org for official definitions.