CMS Pub. 100-04, ch. 32, § 400.4

(RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages

(Rev. 11721; Issued: 11-28-22; Effective: 01-01-23; Implementation: 01-03-23)

Contractors shall continue to use the appropriate existing messages that they have in place when denying claims

submitted that do not meet the Medicare coverage criteria for CAR T-cell therapy.

--Contractors shall deny claims for CAR T-cell therapy when the service is not administered through healthcare

facilities that are enrolled in the FDA REMS requirements using the following messages:

CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

RARC 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 Obligations).

MSN 16.2 – This service cannot be paid when provided in this location/facility.

Spanish Version – Este servicio no se puede pagar cuando es suministrado en esta sitio/facilidad.

In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.

--When denying claims for covered CAR T-cell therapy procedures because the appropriate ICD-10 coding was

not used, use the following messages:

CARC 50 - These are non-covered services because this is not deemed a "medical necessity" by the payer. Usage: Refer

to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC 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 or PR dependent upon liability.

MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”

Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”

--When denying claims for covered CAR T-cell therapy procedures because they are not performed in POS 11 or

49, use the following messages:

CARC 58 Treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service.

Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if

present.

RARC 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 or PR (Patient Responsibility) dependent upon liability. (Use PR when the GA modifier is appended to

the line item).

MSN 09.040 - This item or service was denied because information required to make payment

was incorrect.

MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”

Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”

--When denying claims for covered CAR T-cell therapy procedures because they do not contain new modifier -

LU, use the following messages:

CARC 4 - The procedure code is inconsistent with the modifier used. Usage: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present.

RARC 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

MSN 15.20 - “The following polices were used when we made this decision: NCD 110.24.”

Spanish Version – “Las siguientes políticas fueron utilizadas cuando se tomó esta decisión: NCD 110.24.”

--When denying claims for covered CAR T-cell therapy procedures because the fractional units exceed 1 unit, use

the following messages:

CARC 151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency

of services.

Group Code CO

MSN 15.060 - The information provided does not support the need for this many services or items within this period of

time.

Spanish Version - (La información proporcionada no confirma la necesidad de estos servicios o artículos en este periodo

de tiempo.)

-- Contractors shall reject claims for allogeneic CAR T-cell therapy ICD-10-PCS codes XW033G7 and XW043G7

and autologous CAR T-cell therapy ICD-10-PCS codes XW033C7 and XW043C7 when not billed for clinical

trials under NCD 310.1 with the NCT number for the specific trial, condition code 30, value code D4, and the

Z00.6 clinical trial diagnosis code effective for dates of service on or after October 1, 2021, using the following

messages:

CARC 55: Procedure/treatment/drug is deemed experimental/investigational by the payor.

Group Code: CO

MSN 16.77 – This service/item was not covered because it was not provided as part of a qualifying trial/study.

Spanish Version – (Este servicio/artículo no fue cubierto porque no estaba incluido como parte de un ensayo

clínico/estudio calificado.)

In addition to the codes listed above, contractors shall afford appeal rights to all denied parties.