CARC 50 Denial Appeal

Not medically necessary

These are non-covered services because this is not deemed a 'medical necessity' by the payer.

The winning argument

The denial applies medical-necessity criteria more restrictive than generally accepted clinical standards (e.g., ASAM/LOCUS/APA) and, where comparable medical/surgical care is not held to the same standard, functions as a discriminatory non-quantitative treatment limitation (NQTL) under MHPAEA.

• The clinical record documents functional impairment and risk of decompensation that meet the requested level of care.
• The reviewer failed to weigh the patient's longitudinal history and relapse risk.
• We are entitled to the specific written clinical criteria used to deny, and to peer review by a same-specialty clinician.

Sample appeal letter body

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We are appealing the denial of behavioral health services for {{patient_reference}}, denied under CARC 50 (not medically necessary). This denial conflicts with generally accepted standards of care — specifically {{applicable_guidelines}} — which support the requested level of care given the patient's documented {{primary_symptoms}} and functional impairment in {{functional_impairments}}. Applying criteria that require acute crisis for continued behavioral-health care, where comparable medical/surgical conditions are not held to the same standard, operates as a non-quantitative treatment limitation under the Mental Health Parity and Addiction Equity Act. We formally request the specific written clinical criteria used to deny this claim and a peer review by a board-certified {{specialty}}.