PR-204

Depends on the details

Not covered under the current benefit plan

Group PR — Patient Responsibility — an amount the plan says may be billed to you, the patient.

PR-204 means the insurer determined the service, medication, or piece of equipment isn't a covered benefit under your specific plan. Because it's grouped as Patient Responsibility (PR), the plan is signaling that you may be billed for it.

A PR-204 isn't always the final word. Coverage decisions can be wrong or overly narrow, and what's excluded under one plan may be covered when there's a medical justification, a formulary exception, or a plan document that says otherwise.

Got a PR-204 denial? Our free generator can draft a ready-to-send appeal letter for this denial in a few minutes. Start your appeal →

Why you're seeing PR-204

  • The item or service is genuinely excluded from your plan's benefits.
  • It was billed with a code that maps to a non-covered category, even though a covered alternative exists.
  • A drug isn't on the plan's formulary and no exception was requested.
  • The plan applied the wrong benefit category to the claim.

Can you appeal it?

Depends on the details

Depends on whether the exclusion is real — appeal when there's medical justification, a coding fix, or a formulary/benefit exception available.

What to do next

  1. 1Read your plan's Summary of Benefits and Coverage to confirm whether the item is truly excluded.
  2. 2Ask the insurer exactly which plan provision or exclusion they relied on.
  3. 3If there's a medical reason it should be covered, request a coverage or formulary exception with provider support.
  4. 4Check whether a billing/coding error placed the claim in the wrong benefit category.
  5. 5Appeal in writing if the exclusion is being applied incorrectly or an exception applies.

Evidence that helps

  • Your plan's Summary of Benefits and Coverage or full plan document.
  • A letter of medical necessity if you're requesting an exception.
  • The exact plan provision the insurer cited for the exclusion.

Frequently asked questions

Does PR-204 mean I definitely have to pay?

Not necessarily. The 'PR' group means the plan is billing it to you, but coverage determinations can be wrong or too narrow. If there's a medical justification, a formulary exception, or a coding error, you can appeal.

What's the difference between PR-204 and CO-96?

Both signal a non-covered service, but PR-204 is billed to you as patient responsibility, while CO-96 is a contractual adjustment. PR-204 usually points to a specific plan exclusion; CO-96 typically needs an accompanying remark code to explain the exact reason.

Related guide: How to appeal a “Service not covered / benefit exclusion” denial →

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Other common denial codes

Last reviewed July 18, 2026. Denial-code lists (CARC/RARC) are updated three times a year; we review these explanations against the current list.

Sources & references

These explanations are written in plain language and based on the authoritative sources below. Always confirm the specifics against your own plan documents and denial letter.

Important: this is not legal or medical advice.

AppealBrain is a free, self-help tool that helps you draft an appeal letter using the information you provide. We are not a law firm, medical provider, or insurance company, and using this tool does not create an attorney–client relationship. Appeal rules and deadlines vary by plan and state — always review your own denial letter and plan documents, and consider consulting a licensed professional for your specific situation. We do not guarantee any outcome.