Mental health and addiction treatment: 80% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2026 · Medical necessity · age 21–30 Mental hlth med ad training · Mental health The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program services. Using the LOCUS framework, the patient meets criteria for this level of care. The patient’s…

   The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for partial hospitalization program services. Using the LOCUS framework, the patient meets criteria for this level of care. The patient’s composite score of 21 aligns with the need for medically monitored community‑based services or partial hospitalization. The services provided were and are consistent with generally accepted standards of mental health and substance use disorder treatment, clinically appropriate in scope and duration, and not primarily for convenience. For these reasons, the partial hospitalization program services were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46962

2. Overturned 2026 · Medical necessity · age 51–64 Other MH comm support serv · Mental health The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, the patient met and…

   The physician reviewer found that a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services (ASAM 3.1). Per the American Society of Addiction Medicine (ASAM) criteria, the patient met and continues to meet Level 3.1 criteria for the period under review. Based on the documentation, the patient requires this level of care due to needs identified across multiple ASAM dimensions and is not yet clinically stable enough to transition to a less intensive setting. The RTC level of care was and is consistent with generally accepted standards of mental health and substance use disorder treatment, and the services were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services were not and are not primarily for the economic benefit of the health plan or for the convenience of the patient or providers. As such, the requested RTC services (ASAM 3.1) were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services were an are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry with a subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the member's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46959

3. Overturned 2026 · Medical necessity · age 0–10 Other MH comm support serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for all or any of the applied behavior analysis therapy services: therapeutic behavioral services total of 390 hours…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient’s parent has requested authorization and coverage for all or any of the applied behavior analysis therapy services: therapeutic behavioral services total of 390 hours; mental health service plan development by non-physician 83 additional hours; home care training, family; and skills training and development total 39 hours, with the approved 10 hours of assessments. Per the medical records, the patient has a diagnosis of autism spectrum disorder. The Applied Behavior Analysis Coding Coalition notes that patient information, the reason for referral, brief background information, clinical interview, file review of recent assessments/reports, assessment procedures and results, treatment plan, parent/caregiver training as medically indicated and to the extent practical, number of hours or units requested, coordination of care when applicable, transition plan, discharge plan, and crisis management plan when applicable are all required components of a treatment plan. In this case, the submitted treatment plan includes all of these elements. The patient is responding favorably to treatment, mastering nine goals and making progress on 12 goals during the previous reporting period. Therefore, applied behavior analysis therapy services: therapeutic behavioral services total of 390 hours; mental health service plan development by non-physician 83 additional hours; home care training, family; and skills training and development total 39 hours, with the approved 10 hours of assessments are medically necessary to achieve or maintain age-appropriate growth and development, attain, regain or maintain functional capacity, or improve, support, or maintain the patient’s current health condition. Final Result: The reviewer determined that the requested services are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is licensed B.C.B.A., board-certified in psychology, and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46881

4. Upheld 2026 · Medical necessity · age 31–40 Drug alcohol behav hlth serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services, specifically ASAM level 3.5. Per the American Society of Addiction Medicine (ASAM) criteria, this…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services, specifically ASAM level 3.5. Per the American Society of Addiction Medicine (ASAM) criteria, this patient did not meet Level 3.5 criteria for residential treatment center services for the time period under review. The ASAM criteria focus on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance-use-related risks including the likelihood of engaging in risky substance use and the likelihood of engaging in risky substance use disorder-related behaviors; (5) recovery environment interactions including the ability to function effectively in the current environment, safety in the current environment, and support in the current environment; and (6) patient-centered considerations including barriers to care, patient preferences, and the need for motivational enhancement. Using the ASAM Level 3.5 criteria, this patient did not meet all dimensional criteria for medical necessity and therefore did not qualify for ASAM Level 3.5 treatment for the period under review. In addition, the residential treatment center services were not in accordance with the generally accepted standards of mental health and substance use disorder care, were not clinically appropriate in terms of type, frequency, extent, site, and duration, and were not primarily for the convenience of the patient or provider. For these reasons, the residential treatment center services, specifically ASAM level 3.5, were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in psychiatry with subspecialty certification in addiction psychiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46865

5. Overturned 2026 · Medical necessity · age 21–30 Drug alcohol behav hlth serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for any or all of the requested residential treatment center (RTC) services. The American Association…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for any or all of the requested residential treatment center (RTC) services. The American Association of Community Psychiatrists Level of Care Utilization System (LOCUS) provides a reliable framework for determining the appropriate level of care for adults needing mental health treatment. Using LOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the LOCUS framework, the patient meets the criteria for RTC services.These findings in this case give the patient a composite score of 24, which is consistent with medically monitored residence-based services or RTC. Given the patient’s score of 4 in level of functioning, placement in RTC level of care is also supported. Additionally, in terms of length of stay, the patient meets the criteria for level 5B moderate intensity intermediate stay residential treatment programs with a length of stay of up to 60 days due to serious impairment in expected role functioning in work, school, and home.Furthermore, the requested RTC services are in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, all of the requested RTC were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46852

6. Overturned 2026 · Medical necessity · age 21–30 Drug alcohol behav hlth serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services, specifically ASAM Level 3.1. Per the American…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services, specifically ASAM Level 3.1. Per the American Society of Addiction Medicine (ASAM) criteria, this patient met and continues to meet the Level 3.1 criteria for RTC services for the period under review. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood of engaging in risky substance use and the likelihood of engaging in risky substance use disorder-related behaviors; (5) recovery environment interactions including the ability to function effectively in the current environment, safety in the current environment, and support in the current environment; and (6) patient-centered considerations including barriers to care, patient preferences, and the need for motivational enhancement. Using the ASAM level 3.1 criteria, the patient met and continues to meet the criteria for medical necessity and, therefore, qualifies for ASAM level 3.1 treatment for the time period under review secondary to specific needs identified in dimensions 2, 3, 4, and 5. The patient’s signs and symptoms were and are improving or were and are expected to improve with interventions provided at the ASAM 3.1 level of care, but were not and are not sufficiently clinically stable to support the transition to a less intensive level of care. In this patient’s case, the RTC level of care was and is in accordance with the generally accepted standards of mental health and substance use disorder care. Additionally, the services at issue were and are clinically appropriate in terms of type, frequency, extent, site, and duration. The services at issue were not and are not primarily for the economic benefit of the healthcare service plan and subscribers or for the convenience of the patient, treating physician, or other healthcare provider. As such, the requested RTC services, specifically ASAM Level 3.1, were and are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services were and are medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry with a subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46851

7. Overturned 2026 · Medical necessity · age 51–64 Drug alcohol behav hlth serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center (RTC) services (ASAM 3.5). Per the American Society of Addiction Medicine (ASAM) criteria, this patient met Level 3.5 criteria for RTC services for the time period under review. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and associated risk, withdrawal and associated risks, and addiction medication needs; (2) biomedical conditions including physical health concerns and pregnancy-related concerns; (3) psychiatric and cognitive conditions and history including active psychiatric symptoms and persistent disability; (4) substance use-related risks including the likelihood of engaging in risky substance use and the likelihood of engaging in risky substance use disorder-related behaviors; (5) recovery environment interactions including the ability to function effectively in the current environment, safety in the current environment, and support in the current environment; and (6) patient-centered considerations including barriers to care, patient preferences, and the need for motivational enhancement.Using the ASAM Level 3.5 criteria, this patient met all dimensional criteria for medical necessity and therefore qualified for ASAM Level 3.5 treatment for the time period under review. In addition, the RTC services were in accordance with the generally accepted standards of mental health and substance use disorder care, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient or provider. For these reasons, the RTC services (ASAM 3.5) were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46819

8. Upheld 2026 · Medical necessity · age 0–10 Other MH comm support serv · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for applied behavior analysis therapy services, including direct services 45 hours per month, supervision 10 hours…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for applied behavior analysis therapy services, including direct services 45 hours per month, supervision 10 hours per month, caregiver training 4 hours per month, and reassessment 12 hours across the authorization period.Based on the medical documentation provided, current ABA Practice Guidelines from the Council of Autism Service Providers, the Model Coverage Policy from the ABA Coding Coalition, and published medical necessity criteria do not support the requested services as medically necessary in their current form. ABA treatment plans should include clearly defined short-term, intermediate-term, and long-term goals, comprehensive assessment information, and individualized treatment targets.Review of the submitted treatment plan demonstrates incomplete assessment data and insufficient clarification of treatment goals. The documentation does not consistently define short-term, intermediate-term, and long-term objectives, and relevant assessment information, including results from additional language and learning assessments, is incomplete. As a result, the requested frequency and duration of services cannot be adequately supported based on the information provided.Given these findings, the requested ABA therapy services, including direct services, supervision, caregiver training, and reassessment, are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in psychology and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case MN26-46446

9. Upheld 2025 · Medical necessity · age 11–20 Residential treatment · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient’s parent has requested authorization and coverage for six months of long term residential treatment with an integrated educational program, comprehensive medication…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient’s parent has requested authorization and coverage for six months of long term residential treatment with an integrated educational program, comprehensive medication management, trauma focused therapy, and ongoing behavioral stabilization services. Residential treatment is indicated when a patient requires a structured, 24 hour therapeutic environment due to severity of symptoms and inability to be safely managed at a lower level of care. Clinical guidelines, including CALOCUS criteria, support the least restrictive level of care that is appropriate for the patient’s needs. In this case, the patient’s CALOCUS score is consistent with a recommendation for medically monitored community based services rather than residential treatment. The requested level of care exceeds what is clinically indicated and is not consistent with generally accepted standards of mental health care. The requested services are not appropriate in type, frequency, extent, site, or duration for this patient’s clinical needs. Therefore, the requested long term residential treatment services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the requested services are not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case MN25-46101

10. Upheld 2025 · Medical necessity · age 0–10 Cognitive therapy · Mental health The physician reviewer found that the patient’s parent has requested authorization and coverage for auditory processing disorder testing to include: (1) evaluation of central auditory function, with report initial 60 minutes, (2) evaluation of central…

    The physician reviewer found that the patient’s parent has requested authorization and coverage for auditory processing disorder testing to include: (1) evaluation of central auditory function, with report initial 60 minutes, (2) evaluation of central auditory function, additional 15 minutes, (3) comprehensive audiometry threshold evaluation and speech recognition, (4) evoked otoacoustic emissions, limited, and (5) tympanometry and acoustic reflex testing. Testing patients with diagnoses that affect cognition, such as attention deficit hyperactivity disorder (ADHD), can affect the results of a central auditory processing disorder (CAPD) evaluation or render it invalid. Without complete treatment for ADHD, including physician-recommended medication therapy, it is likely that the untreated symptoms of ADHD for this patient would impact the reliability of a CAPD evaluation. The overlapping clinical features of ADHD and CAPD make differential diagnosis of these conditions challenging. One systematic review found that pediatric patients diagnosed with ADHD and CAPD did not perform significantly differently on a CAPD test battery. The evidence suggests that disorders such as ADHD and CAPD may not be distinct conditions. Additionally, pediatric patients evaluated for attention difficulties may receive a different diagnosis of ADHD or CAPD depending on the background of the professional performing the evaluation as opposed to distinct clinical presentation. Given the likely effects of the incomplete treatment of the patient’s ADHD on the reliability of the requested procedures, and the lack of distinct clinical features to separate ADHD and CAPD, the requested procedures are not indicated. Therefore, the requested auditory processing disorder testing to include: (1) evaluation of central auditory function, with report initial 60 minutes, (2) evaluation of central auditory function, additional 15 minutes, (3) comprehensive audiometry threshold evaluation and speech recognition, (4) evoked otoacoustic emissions, limited, and (5) tympanometry and acoustic reflex testing, is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested service is not medically necessary for the evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is a licensed Au.D., board-certified in audiology and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46032

11. Upheld 2025 · Medical necessity · age 11–20 Residential treatment · Mental health The physician reviewer found that the parent of a patient has requested reimbursement for residential treatment center services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have…

    The physician reviewer found that the parent of a patient has requested reimbursement for residential treatment center services. The American Academy of Child and Adolescent Psychiatry (AACAP) and American Association of Community Psychiatrists (AACP) have unified the Child and Adolescent Level of Care Utilization System (CALOCUS) and the Child and Adolescent Service Intensity Instrument (CASII) into a single instrument, the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII). This instrument provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS-CASII, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) developmental, medical, substance use, and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) resiliency and response to services; and (6) engagement. The composite score is then used to determine the level of care needed. Applying the CALOCUS-CASII framework, the patient did not meet the criteria for residential treatment center services. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient's medical condition. Therefore, the Health Plan's denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case MN25-46030

12. Upheld 2025 · Medical necessity · age 31–40 Residential treatment · Mental health The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services at a residential level of care. Residential treatment…

    The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services at a residential level of care. Residential treatment is indicated for patients who meet established criteria requiring a structured, 24-hour therapeutic environment due to significant clinical needs that cannot be managed at a lower level of care. Standardized criteria evaluate multiple domains, including risk, functional status, comorbid conditions, and treatment needs, to determine the appropriate level of care. In this case, the available documentation does not demonstrate that the patient meets criteria for residential-level services during the time period under review. The patient’s clinical needs can be appropriately managed at a less intensive level of care, and the requested services are not supported as medically necessary based on accepted standards. Therefore, the requested residential treatment services are not medically necessary for the treatment of this patient. Final Result:The reviewer determined that the services at issue were not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications:The reviewer is board-certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

    Case MN25-45815