As you support your patients on their behavioral health journey, having clear, current medical necessity criteria can help streamline prior authorization decisions and reduce delays in care. Below is a quick overview of the criteria Evernorth^® Behavioral Health (Evernorth) uses for utilization management – along with links to the resources you can reference in day-to-day practice.

Each year, Evernorth reviews the clinical criteria used to support utilization management decisions. This most recent review was completed and approved for continued use by our Behavioral Quality Committee in March 2026, with no major changes identified.

Unless contract requirements or federal or state law require different criteria, Evernorth uses the resources below to guide medical necessity reviews across all health plans.

MCG Behavioral Health Guidelines, 30th edition

We use criteria developed by MCG Health^® to guide medical necessity reviews for mental health levels of care.

The American Society of Addiction Medicine (ASAM) Criteria^®1

We use criteria developed by ASAM to guide medical necessity reviews for substance use disorder levels of care. The ASAM Criteria, 3rd edition applies to customers aged 17 and under, and the ASAM Criteria, 4th edition applies to customers aged 18 and older.

Level of Care Utilization System (LOCUS) and the Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII) criteria

For commercial health plans in California, Colorado, and New York, we use these criteria to guide mental health level-of-care medical necessity reviews. LOCUS applies to customers aged 19 and older, and CALOCUS-CASII applies to customers aged 6 through 18.

Evernorth and Cigna Healthcare^® coverage policies

When a coverage policy exists for a service (e.g., autism spectrum disorders², pervasive developmental disorders, or transcranial magnetic stimulation), we use these policies to guide decisions. Our related policy and procedure emphasizes applying criteria based on the individual case and considering the availability of services in the local delivery system.

Evernorth Behavioral Health Prior Authorization and Billing Resource Guide

For billing practices and prior authorization requirements, refer to this guide.

State regulations and licensing standards³

Where applicable, follow your state’s guidance when conducting mental health and substance use disorder level-of-care medical necessity reviews for commercial health plan business.

Our medical necessity guidelines are available under Supporting Behavioral Websites on the Coverage Policies page of the Evernorth Provider portal (Provider.Evernorth.com).

Additional information

We encourage you to use these guidelines as practical tools to support timely, effective care for your patients covered under Evernorth and Cigna Healthcare plans. If you have any questions or have feedback, please call Provider Services at 800.926.2273 or email BEHPrep@Evernorth.com.

1  Evernorth uses the Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders (Revised April 2020) for guidance in conducting medical necessity reviews of substance use disorder levels of care in New York.

2  Evernorth uses MCG Behavioral Health Guidelines for applied behavior analysis level of care in Virginia.

3  Evernorth complies with state-specific laws, as written.