PR-269: Anesthesia Not Covered for This Service

What Does PR-269 Mean?

PR-269 shifts the anesthesia cost to the patient. The payer's plan does not cover anesthesia for this procedure, and the patient is financially responsible for the charge. This pairing occurs when the patient elected anesthesia for a procedure where it is considered optional, or when the plan specifically excludes anesthesia coverage for the billed service.

When CARC 269 appears on a remittance, the payer has determined that anesthesia services are not a covered benefit for the specific procedure that was performed. This denial targets the anesthesia charge specifically — not the underlying surgical or diagnostic procedure. The payer's coverage guidelines either exclude anesthesia entirely for this procedure type, limit the anesthesia modality covered, or cap the number of anesthesia units allowed.

The 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF) often contains additional context for why the anesthesia was denied. This segment may reference a specific payer policy, LCD, or NCD that defines when anesthesia is and is not covered for the procedure in question. Reviewing this segment before taking action is critical because it tells you whether the denial is based on a blanket coverage exclusion or a specific clinical criterion that can be addressed through documentation.

Anesthesia providers, surgical centers, and hospital outpatient departments encounter CARC 269 when billing for anesthesia services on procedures that payers consider minor enough to be performed without anesthesia, or when the type of anesthesia used (e.g., general vs. local) exceeds what the payer covers. Under CO, the anesthesia charge is a contractual write-off. Under PR, the patient is responsible for the anesthesia cost. In both cases, if the anesthesia was medically necessary due to the patient's condition (e.g., anxiety disorder, physical disability, pediatric patient), an appeal with clinical documentation can be effective.

Common Causes

How to Resolve

Review the 835 policy segment for the specific denial reason, verify anesthesia coding accuracy, and appeal with medical necessity documentation if the anesthesia was clinically required.

1. Verify the patient's plan excludes anesthesia for this procedure Confirm with the payer that anesthesia is not a covered benefit for the specific procedure under the patient's plan.
2. Transfer the charge to the patient's account Move the anesthesia charge to the patient responsibility ledger and generate a statement.
3. Contact the patient to explain the charge Inform the patient that their plan does not cover anesthesia for this procedure and discuss the amount owed. Offer payment options.

Common RARC Pairings

The RARC code tells you exactly what triggered the PR-269:

How to Prevent PR-269

• Inform patients before the procedure that anesthesia may not be covered by their plan and obtain financial consent
• Run eligibility verification to check anesthesia coverage before scheduling
• Provide cost estimates that include the anesthesia charge when coverage is uncertain

General Prevention

• Verify anesthesia coverage eligibility for the specific procedure before administering anesthesia services
• Obtain prior authorization for anesthesia when the payer requires it for the planned procedure
• Document medical necessity clearly in patient records, especially when anesthesia is requested for procedures where it is not typically covered
• Maintain effective communication between the surgical team, anesthesia providers, and billing staff regarding coverage limitations
• Monitor payer policy updates on anesthesia coverage requirements
• Ensure accurate anesthesia coding including correct CPT codes, modifiers, and time units

Also Filed As

The same CARC 269 may appear with different Group Codes:

Related Denial Codes