Benefit maximum reached (Updated for 2026)

Common Causes for CO 297

Denials with code CO 297 typically happen for the following specific reasons:

• The patient exceeded the maximum number of allowed visits per benefit year for therapy services, such as physical, occupational, or speech therapy.
• The cumulative dollar amount billed for specialized services, medical equipment, or orthotics exceeded the plan's annual or lifetime benefit cap.
• The patient received similar services from another healthcare provider earlier in the benefit cycle, which exhausted the benefit limits without the current provider's knowledge.
• The claim was processed under the wrong benefit category, mistakenly applying the services to a capped benefit pool instead of an uncapped medical benefit.

How to Prevent CO 297 Denials

To avoid receiving this denial in the future, implement these specific checks:

• Conduct comprehensive real-time eligibility and benefits verification prior to the initiation of treatment to determine remaining visit and dollar limits.
• Utilize an internal electronic health record (EHR) tracking mechanism to count and monitor cumulative visits or dollar amounts billed for capped benefits.
• Obtain a signed financial responsibility waiver, such as an Advance Beneficiary Notice (ABN) for Medicare or a commercial equivalent, before services exceed the benefit cap.
• Submit claims with appropriate clinical documentation and medical necessity modifiers, such as modifier KX for Medicare therapy services exceeding the threshold, to justify exceptions when applicable.

Appeal Letter Template for CO 297

If you believe this claim was denied incorrectly, you can use the following template to submit an appeal.

[Your Practice Header]
[Date]

[Payer Name]
[Appeals Department Address]

RE: Appeal for Claim [Claim Number]
Patient: [Patient Name]
ID: [Patient ID]
Date of Service: [Date]
Denial Code: CO 297 - Benefit maximum reached

Dear Appeals Department,

I am writing to appeal the denial of the above-referenced claim, which was denied with code CO 297: "Benefit maximum reached".

We are writing to appeal the denial of this claim for code CO 297 (Benefit maximum reached). While we acknowledge the patient's standard benefit limitations, the services provided were highly specialized and medically necessary to prevent severe functional deterioration. In accordance with clinical guidelines and CMS policy rules, such as those governing therapy cap exceptions under Section 1833(g) of the Social Security Act, we have documented that the patient meets the criteria for an exception based on clinical complexity and medical necessity. The attached medical records, treatment plans, and objective clinical measures demonstrate that continuing treatment was critical to the patient's recovery. We respectfully request an administrative override or a clinical review to approve coverage for these medically necessary services beyond the standard benefit limit.

Attached please find:
1. A copy of the original claim.
2. The relevant medical records supporting the service.
3. [Any other supporting documents].

We respectfully request that you reprocess this claim for payment.

Sincerely,

[Your Name]
[Title]
[Practice Name]