Appeal: mental health or substance use care with a parity argument
Asks your plan to reverse a mental health or substance use denial and to produce its criteria and comparative analysis under the federal parity law.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. Use this when your plan denied mental health or substance use treatment and you think it applies stricter limits than it applies to medical or surgical care. In 2025 the agencies said they will not enforce the new parts of the 2024 parity rule for now. The 2008 law, the 2013 rule and the comparative analysis duty still apply, and this letter relies only on those. Parity does not reach every plan, for example small-employer plans under the federal employer-plan parity section.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
14 November 2026
[Name and address of the plan's appeals department]
Re: Appeal: mental health or substance use care with a parity argument Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To the reviewer:
I am appealing the decision dated [Date on the denial notice] on claim [Claim or reference number], which denied [The care or drug that was denied] ([Doctor, hospital or pharmacy]) under [Name of the health plan], member ID [Member ID]. The care is mental health or substance use disorder treatment. I ask you to reverse the decision and approve and pay for this care.
The plan gave this reason: [The reason the plan gave] The limit or criteria applied were: [The limit or criteria the plan applied] My treating clinician, [Your treating clinician's name and role], recommends this care. My records show: [What your records show]
Federal law requires a plan that covers both medical and surgical benefits and mental health or substance use disorder benefits to keep limits on the mental health benefits "no more restrictive than the predominant" limits that apply to "substantially all" medical and surgical benefits. A plan that uses limits that are not a dollar amount or a visit count, such as prior authorization or medical necessity criteria, must "perform and document comparative analyses" of how it designs and applies them.
I ask the plan to send me, free of charge and before it decides this appeal: the medical necessity criteria used for this denial; the criteria used for comparable medical or surgical care; the reason for the denial; and the plan's comparative analysis for this type of limit, with the processes and evidence the plan used to apply it. I ask the reviewer to decide whether the limit applied to me meets these requirements as well as whether the care is medically necessary.
Under the federal claims and appeals rules, including Title 29 of the Code of Federal Regulations (CFR), sections 2560.503-1 and 2590.715-2719 (for individual coverage, 45 CFR 147.136), I am entitled to a full and fair review. I ask that someone who was not involved in the first decision, and who is not that person's subordinate, decide this appeal and give no deference to the first decision. Because the denial rests on a medical judgment, I also ask that you consult a health care professional with training and experience in the field of my condition who was not consulted on the first decision. Please consider every record and comment I send, including anything that was not before the first reviewer.
Please send me your decision in writing within the time the rules allow. If you uphold the denial, I will ask for external review by an independent organization and may complain to the agency that regulates my plan.
Enclosures: 1. Copy of the denial letter 2. Letter from my treating clinician 3. Relevant treatment notes and records 4. Any criteria the plan sent me
Sincerely, [Your name]
Before you send it
Send it to the appeals address printed on your denial notice, by a method that proves delivery, such as certified mail with a return receipt or the plan's online portal with a saved confirmation page. Keep a complete copy of the letter and everything you enclose, and write down the date and the method you used.
What to enclose
- Copy of the denial letter
- Letter from my treating clinician
- Relevant treatment notes and records
- Any criteria the plan sent me
What happens next
- Your plan must decide within 30 days after it receives your appeal if the care has not happened yet, or within 60 days if you have already had it. If your plan has two appeal levels, each level gets half that time. Check the date on your notice, which controls.
- If your plan is an employer plan covered by the Employee Retirement Income Security Act (ERISA), the documents you asked for, including the criteria for both kinds of care and any comparative analysis, must be furnished within 30 days of your request. If they do not arrive, tell the agency that oversees your plan.
- If the plan says no again, ask for external review. Whether a plan is following the parity rules on limits like these is a question that can go to external review, as can a medical necessity or level of care decision. For most job-based and individual plans you have at least four months after you receive the final denial. Check the date on your notice, which controls.
- In a bulletin of 8 September 2026 the Employee Benefits Security Administration said it will focus its enforcement on exclusions that apply only to mental health benefits, medical necessity standards and review, and network adequacy. The bulletin says it creates no enforceable rights.
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".
The rule behind this
- 29 U.S.C. 1185a, mental health parity
- 42 U.S.C. 300gg-26, mental health parity (group and individual insurance)
- 29 CFR 2590.712, mental health parity
- Frequently Asked Questions Part 45, Question 6
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 29 CFR 2560.503-1, claims procedure
- Departments' statement on enforcement of the 2024 parity final rule
- EBSA Field Assistance Bulletin No. 2026-03
Sources
- 29 U.S.C. 1185a, mental health parity
- 29 CFR 2590.712, mental health parity
- Frequently Asked Questions Part 45, Question 6
- Departments' statement on enforcement of the 2024 parity final rule
- EBSA Field Assistance Bulletin No. 2026-03
- 29 CFR 2560.503-1, claims procedure
- 29 CFR 2590.715-2719, internal claims and appeals and external review
- 42 U.S.C. 300gg-26, mental health parity (group and individual insurance)
Denial reasons this answers
- Denial reason
Not medically necessary
The plan says the care is not needed under its own definition. That is a medical judgment, so your doctor's letter carries the appeal. Independent external review is open if your plan is not grandfathered, short-term, fixed indemnity or a sharing ministry.
- Denial reason
Level of care
Your plan agrees you need treatment but says a less intensive setting would do. For example, outpatient care instead of residential care, or a lower-intensity program instead of a hospital stay.
- Denial reason
Prior authorization denied
Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.
- Denial reason
Visit or benefit limit reached
Your plan says you used up the visits, days or dollars it covers for a service this year. Check the count, check whether the plan allows more when it is medically necessary, and check whether mental health care is limited more than other care.