CurrentUnitedHealthcarePolicy BIP096.O

Medical Necessity

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This policy governs medical necessity determinations and utilization review for covered mental health and substance use disorder services and benefits under applicable UnitedHealthcare California plans. It applies to UnitedHealthcare and entities or providers performing utilization review or utilization management on its behalf, subject to the member’s Evidence of Coverage and Schedule of Benefits.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Necessity

Policy CodePolicy BIP096.O

Change TypeMaterial coverage criteria update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionUse current generally accepted mental health and substance use disorder standards of care when performing utilization review.

SourceLink

POLICY UPDATE CHANGES

The California Large Groups covered benefits section adds criteria requiring covered services or products to address the member’s specific needs, comply with generally accepted standards of care, be clinically appropriate, and not be primarily for economic or convenience reasons.

90%Minimum interrater reliability pass rate

3Covered-benefit sections to review

2021Effective year of cited California requirements

None

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CurrentUnitedHealthcarePolicy BIP096.O

Medical Necessity

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Policy Summary

PayerUnitedHealthcare

PolicyMedical Necessity

Policy CodePolicy BIP096.O

Change TypeMaterial coverage criteria update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionUse current generally accepted mental health and substance use disorder standards of care when performing utilization review.

SourceLink

POLICY UPDATE CHANGES

90%Minimum interrater reliability pass rate

3Covered-benefit sections to review

2021Effective year of cited California requirements

None

Services specifically listed as not covered

Medical Necessity and Coverage Criteria

General Medical Necessity

An intervention is covered when it is an otherwise covered category of service or item, is not specifically excluded, and is medically necessary or otherwise required to be covered by applicable law or the member's combined Evidence of Coverage.

ALL of the following

The intervention is recommended by the treating physician and determined to be medically necessary by the UnitedHealthcare medical director or network medical group.
The intervention is a health intervention for the purpose of treating a medical condition.
The intervention is the most appropriate supply or level of service, considering potential benefits and harms to the member.
The intervention is known to be effective in improving health outcomes.
For existing interventions, effectiveness is determined first by scientific evidence, then by professional standards, and then by expert opinion. For new interventions, effectiveness is determined by scientific evidence.
If more than one intervention meets the applicable medical-necessity requirements, the intervention is furnished in the most cost-effective manner that can be provided safely and effectively to the member.
Cost-effective does not necessarily mean the lowest price.

California Large Groups Coverage Criteria

For California Large Groups, a service or product addressing the member's specific needs is covered under the applicable coverage requirements when it meets all of the following criteria.

ALL of the following

The service or product is for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing progression of the illness, injury, condition, or symptoms.
The service or product is provided in accordance with generally accepted standards of care, including generally accepted standards of mental health or substance use disorder care.
The service or product is clinically appropriate in terms of type, frequency, extent, site, and duration.
The service or product is not primarily for the economic benefit of the health care service plan and members or for the convenience of the member, treating physician, or other health care provider.

An intervention may be medically indicated yet not be a covered benefit if it does not meet the applicable medical-necessity requirements, is not otherwise required to be covered under applicable law, or is not otherwise set forth as covered in the member's combined Evidence of Coverage. All services must be medically necessary, and each benefit plan has its own coverage provisions, limitations, and exclusions.

Covered benefits are described in the Federal/State Mandated Regulations, State Market Plan Enhancements, and Covered Benefits sections. The member's Evidence of Coverage or Schedule of Benefits governs if it conflicts with this policy. Refer to the member's Evidence of Coverage for information regarding timely access to medically necessary care.

Provider Review and Denial Safeguards

Documentation Required

Document Purchased or Licensed Criteria

Before using purchased or licensed utilization review criteria for mental health or substance use disorder services, verify and document that the criteria were developed in accordance with current generally accepted standards of care. This applies when the criteria address services outside the scope of the applicable professional-association criteria or advancements in technology or types of care not covered by those criteria.

Document the verification before the criteria are used.
Confirm the criteria were developed in accordance with current generally accepted standards of mental health and substance use disorder care.

Denial Risk

Do Not Use Prohibited Denial Bases

Do not deny a provider's request for authorization or claim reimbursement for mental health services based on whether the admission was voluntary or involuntary, or on the method of transportation to the health facility.

California Behavioral Health Requirements

California requirements apply to medical necessity determinations and utilization review for covered mental health and substance use disorder services. Reviews must use current generally accepted standards of care and the most recent treatment criteria and guidelines developed by the relevant nonprofit professional association. For level-of-care placement and other patient-care decisions within the scope of those criteria, review may not apply different, additional, conflicting, or more restrictive requirements. Covered interventions must also be clinically appropriate, effective, and furnished at the appropriate level of service.

Key Policy Definitions

Generally Accepted Standards of Care

DefinitionStandards of care and clinical practice generally recognized by health care providers practicing in relevant clinical specialties.

Relevant specialtiesIncludes psychiatry, psychology, clinical sociology, addiction medicine, counseling, and behavioral health treatment.

Evidence-based sourcesIncludes peer-reviewed scientific studies and medical literature; clinical practice guidelines and recommendations from nonprofit health care provider professional associations, specialty societies, and federal government agencies; and U.S. Food and Drug Administration-approved drug labeling.

Mental Health and Substance Use Disorders

California statutory referenceMental health and substance use disorders have the same meaning as defined in paragraph (2) of subdivision (a) of California Health and Safety Code Section 1374.72.

Policy Summary

PayerUnitedHealthcare

PolicyMedical Necessity

Policy CodePolicy BIP096.O

Change TypeMaterial coverage criteria update

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionUse current generally accepted mental health and substance use disorder standards of care when performing utilization review.

SourceLink

On This Page

Prohibited denial basis: voluntary versus involuntary admission status.
Prohibited denial basis: method of transportation to the health facility.

Denial Risk

Avoid Conflicting or Restrictive Review Criteria

For mental health and substance use disorder utilization review, use current generally accepted standards of care and the most recent treatment criteria and guidelines developed by the nonprofit professional association for the relevant clinical specialty. Do not apply additional, conflicting, or more restrictive criteria to level-of-care placement or other patient-care decisions within the scope of those sources.

Criteria must be based on current generally accepted standards of mental health and substance use disorder care.
Apply the most recent relevant professional-association treatment criteria and guidelines.
Additional, conflicting, or more restrictive criteria are prohibited for decisions within the scope of those sources.
Criteria may address services outside the sources' scope or technological advances not covered by them only when developed in accordance with current generally accepted standards.

Denial Risk

Verify Coverage Requirements Before Denial

An intervention is covered only when it is an otherwise covered service or item, is not specifically excluded, and is medically necessary or otherwise required by law or the member's Evidence of Coverage. A service may be medically indicated yet not covered when it does not meet those coverage requirements; the member's EOC or Schedule of Benefits governs if it conflicts with this policy.

Medical necessity requires treatment of a medical condition; the most appropriate supply or level of service considering benefits and harms; known effectiveness based on applicable evidence, professional standards, or expert opinion; and, when alternatives qualify, the safest and most effective cost-effective option.
Services must comply with generally accepted standards of care and be clinically appropriate in type, frequency, extent, site, and duration.
Services primarily for economic benefit or convenience are not covered under the stated medical-necessity standard.
Always verify the member's specific coverage, limitations, exclusions, and applicable EOC/Schedule of Benefits.

Statutory incorporation

The policy incorporates the meaning assigned to these disorders under the cited California statute.

Policy scopeThe definition applies to covered health care services and benefits for the diagnosis, prevention, and treatment of mental health and substance use disorders, including prescription drugs.

Utilization Review

Prospective reviewReviewing and approving, modifying, delaying, or denying requests for coverage before health care services are provided, based in whole or in part on medical necessity.

Concurrent reviewReviewing and approving, modifying, delaying, or denying coverage requests concurrently with the provision of health care services, based in whole or in part on medical necessity.

Retrospective reviewReviewing and approving, modifying, delaying, or denying coverage requests retrospectively after health care services are provided, based in whole or in part on medical necessity.

Evaluation factorsEvaluating the medical necessity, appropriateness, level of care, service intensity, efficacy, or efficiency of health care services, benefits, procedures, or settings to determine whether coverage is medically necessary.

Utilization Review Criteria

DefinitionAny criteria, standards, protocols, or guidelines used by a health care service plan to conduct utilization review.

Included materialsMay include criteria, standards, protocols, and guidelines used in reviewing coverage requests.

Responsible entityThe criteria are used by a health care service plan when conducting utilization review.