Mental health / substance use benefit denied more strictly than medical
Mental Health Parity denial appeal letter
Denials of therapy, residential, or SUD care with stricter limits than a comparable medical service.
Use this letter to formally appeal a "mental health / substance use benefit denied more strictly than medical" denial. Replace every {{PLACEHOLDER}} with your own facts, attach the listed evidence, and send it certified mail plus by the insurer's online portal.
Template
{{MEMBER_NAME}}
{{MEMBER_ADDRESS}}
{{MEMBER_PHONE}}
Member ID: {{MEMBER_ID}}
Claim / Reference #: {{CLAIM_NUMBER}}
Date of Service: {{DATE_OF_SERVICE}}
Date of Denial Notice: {{DENIAL_DATE}}
{{INSURER_NAME}}
Appeals and Grievances Department
{{INSURER_APPEAL_ADDRESS}}
Re: Formal Internal Appeal — {{CLAIM_NUMBER}}
I am appealing the denial of {{SERVICE}} for {{DIAGNOSIS_ICD10}} on parity grounds.
Under the Mental Health Parity and Addiction Equity Act (29 USC 1185a) and its implementing regulations, financial requirements and treatment limitations on mental health / substance use benefits cannot be more restrictive than the predominant limits on medical/surgical benefits.
I request:
1. A copy of the plan's Non-Quantitative Treatment Limitation (NQTL) comparative analysis relevant to this denial;
2. Documentation of how the medical necessity criteria applied here compare to the criteria for an analogous medical/surgical benefit;
3. Reversal of the denial, since the current review appears to impose a stricter standard than for medical/surgical care.
Sincerely,
{{MEMBER_NAME}}Key points before you send it
- Request the plan's NQTL comparative analysis under MHPAEA.
- Compare medical/surgical limits with the mental health limit that produced the denial.
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Not legal or medical advice. This page is a self-help resource. You make your own decisions. Strip personal identifiers (name, date of birth, address, member ID) from any document before uploading or sharing. The information here summarizes commonly-published payer policies and federal rules; confirm against your specific plan document and the current denial letter before acting.