Who has to pay after a code 269 denial?

Who owes depends on the details. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.

How long do I have to appeal?

It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.

All denial codes · code 269

Denial code 269: what it means — and how to fight it

Denial code 269 (shown on your EOB as CO-269 or PR-269) means: “Anesthesia not covered for this service/procedure.” In plain English: The plan will not pay for sedation for this procedure, usually saying it was not medically necessary for that type of service.

medium appealability Who owes depends on the details

What they're really saying

“Anesthesia not covered for this service/procedure.”

The plan will not pay for sedation for this procedure, usually saying it was not medically necessary for that type of service.

Your odds

Worth fighting — many of these get fixed.

Winnable when the anesthesiologist or proceduralist documents why sedation was required for you specifically.

Fewer than 1 in 100 denied claims are ever appealed. When people do appeal, roughly 4 in 10 win the first round — and independent external review overturns 40–50% of what reaches it.

How to appeal a code 269 denial

Decode. You just did — this page is step one.
Set your clock. 180 days for most employer and marketplace plans, 120 for Original Medicare, ~90 for Medicaid, only 65 for Medicare Advantage.
Urgent? If this is care you still need, call and request an expedited appeal — they must decide within 72 hours.
Ask the anesthesiologist for a note explaining why sedation was required in your case. Get a note explaining why sedation was necessary — anxiety disorder, prior failed attempt without sedation, anatomy, age, or a condition requiring airway management. For screening colonoscopies, note that preventive services are generally required to be covered without cost sharing, and argue the anesthesia is integral to the screening. Ask which policy the plan applied.
Send it certified. Letter plus evidence, keep copies of everything.
Escalate. Denied again? Independent external review — a doctor who doesn't work for your insurer decides.

Do it in minutes, free

The AppealClock tool translates your denial, drafts your appeal letter, computes your exact deadline — and watches the clock so you don't have to. No account. Your medical details never leave your device.

Start your appeal & set your clock →

Common questions

What does denial code 269 mean?: The plan will not pay for sedation for this procedure, usually saying it was not medically necessary for that type of service.
Can I appeal a CO-269 or PR-269 denial?: Yes. Appealing is free and it is your legal right. For this code the odds are medium: Winnable when the anesthesiologist or proceduralist documents why sedation was required for you specifically. Fewer than 1 in 100 denials are ever appealed — insurers count on silence.
Who has to pay after a code 269 denial?: Who owes depends on the details. The letters in front of the number matter: CO (contractual obligation) usually means an in-network provider must absorb it, while PR (patient responsibility) means the plan says you owe it.
How long do I have to appeal?: It depends on your coverage: 180 days for most employer and marketplace plans, 120 days for Original Medicare, about 90 days for Medicaid (varies by state), and only 65 days for Medicare Advantage. Set your deadline clock before you do anything else.