Who has to pay after a code 272 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.

Denial code 272 · CO-272 / PR-272 · translated

Denial code 272: what it means — and how to fight it

Denial code 272 (shown on your EOB as CO-272 or PR-272) means: “Coverage/program guidelines were not met.” In plain English: A vague "you didn't meet the guidelines." Vague denials are weak denials — make them cite the guideline.

medium appealability Who owes depends on the details

What they're really saying

“Coverage/program guidelines were not met.”

A vague "you didn't meet the guidelines." Vague denials are weak denials — make them cite the guideline.

Your odds

Worth fighting — many of these get fixed.

Insurers often can't produce a guideline that actually fits.

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 272 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 in writing: "Which specific guideline, and which criterion was not met?" Demand the specific guideline and clinical criteria. Rebut with physician documentation; escalate to external review where real criteria get 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 272 mean?: A vague "you didn't meet the guidelines." Vague denials are weak denials — make them cite the guideline.
Can I appeal a CO-272 or PR-272 denial?: Yes. Appealing is free and it is your legal right. For this code the odds are medium: Insurers often can't produce a guideline that actually fits. Fewer than 1 in 100 denials are ever appealed — insurers count on silence.
Who has to pay after a code 272 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.