Medical Necessity Criteria

The standards a payer uses to determine whether a service is clinically appropriate and required. Under MHPAEA, the criteria applied to mental health services must be no more restrictive than the criteria applied to analogous medical/surgical services. Payers must disclose their MH/SUD medical necessity criteria on request (CAA 2021 § 203). Wit v. United Behavioral Health (N.D. Cal. 2019) found UBH's internal coverage criteria more restrictive than generally accepted clinical standards; the Ninth Circuit substantially reversed those holdings in 2022 (opinion amended 2023) and remanded. Cite Wit only as a persuasive illustration of MHPAEA/ERISA concerns — not as binding precedent.