Mental Health Claim Denied

What Strengthens Your Appeal

• ✓Evidence that the denial criteria used are stricter than criteria applied to analogous medical/surgical services (MHPAEA parity analysis)
• ✓Psychiatrist or therapist Letter of Medical Necessity with DSM-5 diagnosis and treatment rationale
• ✓Evidence that the level of care is appropriate using LOCUS, ASAM, or CASII criteria
• ✓Documentation that a less intensive level of care failed or is clinically inappropriate
• ✓Clinical guidelines from the American Psychiatric Association (APA) or SAMHSA supporting the treatment
• ✓Evidence of patient safety risk if treatment is terminated or reduced

Appeal Packet: What to Include

• 1Denial letter with specific criteria used for denial
• 2Treating clinician's Letter of Medical Necessity with DSM-5 diagnosis
• 3Clinical records showing history, diagnosis, and treatment progress
• 4Level of care criteria analysis (LOCUS, ASAM, CASII)
• 5MHPAEA parity comparison if the plan applies stricter limits to mental health than medical care
• 6APA clinical guidelines supporting the treatment
• 7Documentation of patient safety concerns if relevant

What to Ask Your Doctor or Provider

Your provider plays a key role in your appeal. Ask them for:

• →A detailed Letter of Medical Necessity with DSM-5 diagnosis and treatment justification
• →Level of care assessment using standardized criteria (LOCUS, ASAM, CASII)
• →Documentation of clinical necessity, safety risks, and consequences of denied treatment
• →Any prior treatment history showing what has been tried

Step-by-Step Escalation

If your first appeal fails: File a Mental Health Parity complaint with the Department of Labor (EBSA) or your state insurance department. MHPAEA enforcement is increasing and many insurers are being required to reprocess improperly denied mental health claims.

Related Denial Reasons