US · guidance
CMS Pub. 100-04, ch. 32, § 150.7
Medicare Summary Notices (MSNs) and Claim Adjustment Reason Codes
When rejecting/denying claims because bariatric surgery procedures were performed in an unapproved
facility use:
• MSN 16.2 - "This service cannot be paid when provided in this location/facility."
• Claim Adjustment Reason Code 58 - "Payment adjusted because treatment was deemed by the
payer to have been rendered in an inappropriate or invalid place of service."
• Remittance Advice Remark Code N386 - “This decision was based on a National Coverage
Determination (NCD). An NCD provides a coverage determination as to whether a particular item or
service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not
have web access, you may contact the contractor to request a copy of the NCD.”
When rejecting/denying claims for non-covered bariatric surgery procedures use:
• MSN16.10 - Medicare does not pay for this item or service.
• Claim Adjustment Reason Code 50 - "These are non-covered services because this is not deemed a
“medical necessity” by the payer."
• Remittance Advice Remark Code N386 - “This decision was based on a National
Coverage Determination (NCD). An NCD provides a coverage determination as to whether a
particular item or service is covered. A copy of this policy is available at
www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to
request a copy of the NCD.”
•
When rejecting/denying claims for covered bariatric surgery procedures because the patient did not meet the
conditions for coverage use:
• MSN 15.4 - “The information provided does not support the need for this service or item.”
• Claim Adjustment Reason Code 167 - "This (these) diagnosis(es) is (are) not covered”
• Remittance Advice Remark Code N386 - “This decision was based on a National
Coverage Determination (NCD). An NCD provides a coverage determination as to whether a
particular item or service is covered. A copy of this policy is available at
www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to
request a copy of the NCD.”
• Group Code CO – Contractual Obligation
In addition to the codes listed above, afford appeal rights to all denied parties.
History
(Rev. 11021; Issued: 10-01-21; Effective: 10-29-21; Implementation: 10-29-21)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
6b6e5c346f18549a22c7582d426b0cf2cb2a83b914e5427102e11102a212e2e2
The link goes to the issuing authority’s own document — the one we read to produce this record. Where a source publishes whole titles rather than sections, your browser may need a moment to jump to the provision.
Unofficial copy of government-published law, reproduced from official sources with full provenance. Not an official publication; verify against official sources before relying on it in a filing. Records in the 'guidance' corpus, and only that corpus, are sub-regulatory (interpretive guidelines, survey procedures) and are not binding law. Validity bounds follow each jurisdiction's declared temporalBasis.