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We have provided two sets of resources to support clinician and patient efforts to secure insurance coverage for medically necessary behavioral health treatment. These resources are grounded in principles of effective treatment that reflect generally accepted standards of care within the behavioral health and psychiatric medical community.
- Download the “Eight Principles of Effective Treatment That Reflect Generally Accepted Standards of Care”
- Practical information and sample text for how to write an effective letter of medical necessity. Medical necessity letters can be used to proactively help patients obtain insurance coverage for medically necessary care.
- Practical information and sample text for how to write an effective appeal letter. These appeal letters support patient/member appeals of denials based on lack of “medical necessity,” a common reason given for health care denials.
Disclaimer: These sample medical necessity and appeal letters and templates provide information not legal advice and should not be viewed as a comprehensive step-by-step appeal process guide. Rather, these resources offer information that may help to guide your approach to seeking insurance coverage. Appeals processes are complex and highly individualized. It is best to consult an insurance claims expert prior to pursuing an appeal.
Writing an Effective Letter of Medical Necessity
In their 2021 column “Providing a Routine Medical Necessity Letter to Improve Access to Care for Our Patients”, authors explained the value of providing a “medical necessity letter” to help patients secure insurance coverage. Using the Mental Health Parity and Addiction Equity Act and the landmark verdict in the federal class action known as Wit v. United Behavioral Health/Optum, the authors offered a framework for how to construct such a letter with supporting text and resources.
The authors outlined 4 key elements in an effective medical necessity letter:
- A statement of provider credentials;
- A description of your practice, including level of experience and expertise in treating people with specific mental and substance use disorders;
- A clinical assessment of the patient, especially unique aspects of the patient’s presentation, history, or living circumstances; and
- Most importantly, an explanation as to why the course of treatment is “medically necessary,” including the rationale (clinical decision-making process) justifying that treatment.
Unfortunately, on March 22, 2022, a 3-judge panel of the United States Court of Appeals for the Ninth Circuit Court reversed the decision in Wit v. United Behavioral Health/Optum. Plaintiffs’ attorneys have requested a review by the entire 29-member Ninth Circuit. While we await the Court’s response, the following modifications to the author’s suggested template and text are offered, with permission.
Appendix A provides a revised template, with suggested text, for a medical necessity letter. (Download Appendix A)
In addition, the following sample letters illustrate how you might apply the template to a specific clinical scenario. Of note, we have highlighted or otherwise denoted areas in each letter that will require you to modify the text to suit your individual needs. The sample medical necessity letters include footnotes in Roman numerals to be deleted once you have edited your letter and endnotes in Arabic superscripts to be retained to preserve the integrity of the letter. Please be sure to review and modify accordingly the supra citations as these may shift as you edit.
Appendix B offers language that may assist in writing a medical necessity letter to help patients secure insurance coverage for residential treatment. (Download Appendix B)
Appendix C offers language that may assist in writing a medical necessity letter to help patients secure insurance coverage for outpatient psychotherapy services. (Download Appendix C)
Writing an Effective Appeal Letter Based on Lack of “Medical Necessity”
These sample appeal letters contain language specific to adverse medical necessity determinations for residential treatment. However, they can be modified to reflect the medical necessity for treatment throughout the continuum of care. Of note, we have highlighted or otherwise denoted areas in each letter that will require you to modify the text to suit your individual needs. The sample letters include footnotes in Roman numerals to be deleted once you have edited your letter and endnotes in Arabic superscripts to be retained to preserve the integrity of the letter. Please be sure to review and modify accordingly the supra citations as these may shift as you edit.
Appendix D offers a framework, with sample text and resources, that may assist in supporting a patient/member appeal of an adverse medical necessity determination when the insurer(or the third-party claims administrator) has used multidimensional access to care criteria developed by nonprofit professional sources of accepted standards, such as the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS)or the Child and Adolescent Level of Care Utilization System (CALOCUS) developed by the American Association of Community Psychiatrists, or the American Society of Addiction Medicine (ASAM) criteria. (Download Appendix D)
Appendix E offers a framework, with sample text and resources, that may assist in supporting a patient/member appeal of an adverse medical necessity determination when the insurance company (or the third-party claims administrator) has used proprietary access to care criteria that are not recognized by practitioners and medical specialty groups (e.g., MCG Guidelines, InterQual). In this case example, a third-party claims administrator adjudicated and denied the request for benefits on behalf of the member’s insurance company. Sample language is provided for how to acknowledge this point. The template also includes suggestions for how to discuss co-occurring conditions such as substance-related and addictive disorders. (Download Appendix E)
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