PR-56: Procedure / Treatment Not Deemed Effective

What Does PR-56 Mean?

PR 56 shifts financial responsibility to the patient because their plan excludes treatments the payer considers ineffective for the billed condition. This may occur when the patient chose to continue treatment after the payer communicated that further sessions would not be covered. The provider can bill the patient for the full amount.

CARC 56 is the payer's clinical judgment that the treatment or procedure billed has not demonstrated effectiveness for the patient's specific condition. This differs from CARC 50 (not medically necessary) and CARC 55 (experimental) in an important way: the payer is not saying the treatment lacks evidence or is not needed — they are saying the evidence shows it does not work, or that it has not produced measurable results for this patient.

This denial frequently appears in rehabilitation settings (physical therapy, occupational therapy, speech therapy) where a payer determines that the patient has reached a treatment plateau and continued sessions are no longer producing functional improvement. It also applies to treatments where the payer has reviewed the clinical literature and concluded the procedure is not effective for the specific diagnosis billed. A common scenario is a therapy clinic that has been seeing a patient for several months, and the payer's utilization review determines that objective functional scores are no longer improving.

The group code matters significantly. CO 56 means the provider must absorb the cost or appeal — the key is presenting clinical evidence of effectiveness, including objective functional assessments and measurable improvement data. PR 56 means the patient is responsible, typically because their plan excludes treatments the payer deems ineffective. For either group code, the appeal strategy centers on demonstrating that the treatment has produced or will produce measurable clinical benefit.

Common Causes

How to Resolve

Demonstrate treatment effectiveness through clinical documentation showing measurable patient improvement and peer-reviewed evidence supporting the treatment for the specific condition.

1. Confirm the exclusion Verify that the patient's plan excludes the treatment for the billed condition and that the effectiveness determination is current.
2. Inform the patient Explain the denial and the patient's financial responsibility. Discuss whether continued treatment is clinically appropriate given the payer's determination.
3. Assist with appeal if appropriate Help the patient file a member-level appeal with clinical documentation if the effectiveness determination appears incorrect.

How to Prevent PR-56

• Inform patients when their payer may consider the treatment ineffective and obtain financial responsibility forms before continuing.
• Monitor payer communications about treatment effectiveness determinations and communicate changes to patients promptly.
• Explore alternative covered treatments that may achieve similar clinical outcomes.

General Prevention

• Inform patients about potential non-coverage before starting treatments that may be deemed not effective by their payer.
• Obtain signed financial responsibility forms before rendering treatments with uncertain coverage.
• Help patients verify their plan's coverage for specific treatments before initiating care.

Also Filed As

The same CARC 56 may appear with different Group Codes:

Related Denial Codes