Addiction Treatment Insurance Denied: How to Appeal Using MHPAEA

Addiction Treatment Insurance Denied: How to Appeal Using MHPAEA

Substance use disorder (SUD) — including alcohol use disorder, opioid use disorder, and other drug addictions — is a clinically recognised medical condition. Insurance companies are legally required to cover SUD treatment at the same level as other medical conditions under federal law. But denials for detox, rehabilitation, medication-assisted treatment (MAT), and residential SUD programmes are among the most common — and most potentially life-threatening — insurance denials.

If your insurer has denied addiction treatment, you have powerful legal rights to fight back. This guide explains how.

The Law: Mental Health Parity and Addiction Equity Act (MHPAEA)

MHPAEA is the most important federal law governing SUD treatment insurance coverage. Enacted in 2008 and strengthened over time, MHPAEA prohibits health insurers from:

• Applying stricter limits on SUD treatment benefits than on medical/surgical benefits
• Requiring more intensive prior authorisation for SUD treatment than for comparable medical treatment
• Using more restrictive medical necessity criteria for SUD treatment than for medical care
• Applying annual or lifetime day limits to SUD treatment that don't apply to comparable medical treatment

This means that if your plan covers 30 days of inpatient cardiac rehabilitation, it generally cannot limit inpatient SUD rehabilitation to fewer days.

The 2024 MHPAEA Final Rule: The Department of Labor, HHS, and Treasury issued a strengthened MHPAEA final rule in 2024 that further tightened requirements, mandating insurers to perform and document comparative analysis of their SUD and medical benefits, and making this analysis available to consumers upon request.

Common Addiction Treatment Denial Reasons

Medical detoxification denied: Insurer argues medical detox is not necessary and outpatient management is sufficient. This can be dangerous — alcohol and benzodiazepine withdrawal can be fatal without medical supervision.

Residential treatment denied: Insurer argues intensive outpatient (IOP) is sufficient, denying the residential level of care.

Step-down care denied: After inpatient or residential treatment, insurer denies the next level of care (partial hospitalisation, IOP) claiming no further treatment is necessary.

"Non-medically necessary" residential care: Insurer classifies residential SUD treatment as custodial or non-medical in nature.

Prior authorisation issues: Insurer refuses to pre-authorise residential or intensive treatment.

Medication-Assisted Treatment (MAT) denied: Insurer denies coverage for buprenorphine, methadone, or naltrexone — FDA-approved medications for opioid and alcohol use disorder. This is increasingly a MHPAEA violation as these medications are evidence-based medical treatments.

Specific facility not covered: Insurer denies coverage because the treatment facility is not in-network.

ASAM Criteria: The Standard for Level of Care

The American Society of Addiction Medicine (ASAM) Criteria is the nationally recognised standard for determining the appropriate level of care for SUD treatment. ASAM assesses six dimensions:

1. Acute intoxication/withdrawal potential
2. Biomedical conditions
3. Emotional/behavioural conditions
4. Readiness to change
5. Relapse/continued use potential
6. Recovery environment

If your treating physician or certified addiction specialist determines that residential or intensive treatment is indicated under ASAM criteria, your appeal should explicitly reference ASAM and your clinician's assessment of each dimension.

Step-by-Step: Appealing an Addiction Treatment Denial

Step 1: Get the Written Denial

Ensure you have a written denial specifying the denial reason, the clinical criteria applied, and your appeal rights.

Step 2: Invoke MHPAEA Immediately

In writing, contact your insurer and request:

1. The specific medical necessity criteria applied to the denied SUD treatment
2. A comparative analysis demonstrating these criteria are no more restrictive than the criteria applied to comparable medical/surgical inpatient or intensive treatment
3. Your plan's annual and lifetime limits for SUD treatment vs. medical/surgical treatment

This request puts the insurer on notice. Federal regulations require the insurer to provide this information.

Step 3: Gather Clinical Documentation Using ASAM Criteria

Your treating addiction medicine physician, psychiatrist, or certified addiction counsellor should provide:

• A detailed ASAM assessment across all six dimensions explaining why the denied level of care is clinically indicated
• Documentation of the dangers of a lower level of care (for detox denials — risks of medically unsupervised withdrawal)
• Prior treatment history documenting that lower levels of care have been insufficient
• Physician's letter explaining why MAT is medically necessary (for medication denials)

Step 4: Emergency Protections for Detox

If the denial involves medical detoxification from alcohol or benzodiazepines:

• Document medically that unsupervised withdrawal carries life-threatening risks (seizures, delirium tremens)
• Request an expedited appeal — the insurer must respond within 72 hours
• If necessary, pursue emergency admission and challenge the denial retroactively — courts and external reviewers take life-threatening denial circumstances very seriously

Step 5: Submit Your Appeal

Your appeal letter should:

• Invoke MHPAEA by name
• Reference the insurer's failure to provide the comparative analysis (if they haven't)
• Include your clinician's ASAM-based assessment
• Document history of failed lower-level-of-care treatment
• Address each element of the insurer's denial criteria directly

Step 6: Request External Review

After exhausting internal appeals, request external review. External reviewers apply ASAM criteria and national standards — not insurer-internal criteria. External reviews of SUD residential treatment denials have high success rates, particularly when MHPAEA is invoked.

Step 7: File Regulatory Complaints

Department of Labor: For ERISA plans — file an MHPAEA complaint at dol.gov/agencies/ebsa State Department of Insurance: For fully insured plans — file with your state's insurance regulator Substance Abuse and Mental Health Services Administration (SAMHSA): samhsa.gov for resources and referrals

Step 8: Contact SUD Advocacy Organisations

• Faces & Voices of Recovery: facesandvoicesofrecovery.org
• American Society of Addiction Medicine (ASAM): asam.org — can help find addiction medicine physicians who understand parity rights
• Legal Action Center: lac.org — provides legal assistance for insurance parity claims
• National Alliance on Mental Illness (NAMI): nami.org

MAT-Specific Appeals: Buprenorphine and Methadone

Medication-Assisted Treatment (MAT) with buprenorphine (Suboxone), methadone (at opioid treatment programs), and naltrexone (Vivitrol) is the most effective evidence-based treatment for opioid use disorder. If your insurer is denying MAT:

MHPAEA violation: Denying MAT for opioid use disorder while covering comparable medications for other chronic conditions (e.g., insulin for diabetes) is an MHPAEA violation.

Step therapy: Requiring "abstinence-based" treatment before MAT is clinically indefensible and increasingly viewed as an MHPAEA violation. Include in your appeal documentation from the American Society of Addiction Medicine, American Academy of Addiction Psychiatry, and other bodies establishing MAT as the first-line treatment for opioid use disorder.

Methadone at opioid treatment programs (OTPs): Medicare and Medicaid are required to cover methadone for OUD at certified OTPs. Commercial insurance denials of OTP methadone are typically MHPAEA violations.

Conclusion

Substance use disorder treatment denials are often life-threatening and almost always legally challengeable under MHPAEA. The law is clear: insurers cannot discriminate against SUD treatment. Invoke MHPAEA, use ASAM criteria, get your addiction medicine physician's documentation, and escalate to external review and regulatory complaints. Lives literally depend on getting this treatment covered. Use ClaimBack at claimback.app to generate a professional appeal letter for your addiction treatment insurance denial.

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Related Reading:

• Mental Health Residential Treatment Denied: How to Appeal
• How to Negotiate with Your Insurance Company
• Can You Sue Your Insurance Company?
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies