Residential and level-of-care denials
Behavioral health and substance-use disorder denials often turn on level-of-care decisions — residential vs. partial hospitalization vs. intensive outpatient. Carriers frequently deny residential placement using internal criteria that have been ruled inadequate in landmark litigation, including Wit v. United Behavioral Health.
What gets denied
- Residential mental health treatment
- Residential substance-use disorder treatment
- Eating disorder residential and partial hospitalization
- Adolescent residential placement
- Extended inpatient psychiatric stays
Common denial reasons
- Plan claims a lower level of care is appropriate
- Plan applies internal criteria inconsistent with generally accepted standards
- Plan requires demonstrated failure at lower level of care
- Documentation of acute risk insufficient per plan criteria
How we approach the appeal
Cite generally accepted standards of care — ASAM Criteria for SUD, LOCUS / CALOCUS for MH, APA practice guidelines. Reference Wit v. United Behavioral Health for the principle that plans must use criteria consistent with generally accepted standards, not internally restrictive ones. Pair with a federal MHPAEA parity argument. Document acute risk factors (suicidality, self-harm history, prior treatment failures) precisely.
Urgent: 72 hours. Standard internal appeal: 30 days. External review: 4 months from final internal denial. For active treatment denials, request expedited review.
$5,000 – $150,000+ per episode of care
- · Denial letter and plan's level-of-care criteria
- · Treating clinician's clinical assessment
- · ASAM / LOCUS / CALOCUS scoring (where applicable)
- · Documentation of prior treatment attempts and outcomes
- · Acute risk documentation
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Start Your AppealThis page provides general information about appeal strategy. It is not legal advice. Outcomes depend on documentation, plan terms, and timing.