Evernorth Behavioral Health uses the MCG™ Behavioral Health Guidelines for guidance in conducting mental health level of care medical necessity reviews for all health plan business unless contractual requirements, or federal or state law require the use of other clinical criteria.

In addition, the following resources are used to make medical necessity determinations:

• The ASAM Criteria^®: We use these criteria, developed by the American Society of Addiction Medicine, for guidance in conducting medical necessity reviews of substance use disorder levels of care for all health plan business, unless contractual requirements, or federal or state law require the use of other clinical criteria.
• LOCUS^© and CALOCUS^© – CASII Criteria: We use the following criteria in California for guidance in conducting medical necessity reviews of mental health levels of care for all health plan business, unless contractual requirements, federal law, or state law require use of other clinical criteria.
  • LOCUS Criteria
  • CALOCUS-CASII Criteria

• Cigna Healthcare℠ Medical Coverage Policies
• Evernorth Behavioral Health Prior Authorization and Billing Resource Guide
• State regulations and licensing standards^*

We will continue to use Evernorth Behavioral Health Coverage Policies when one exists for a particular service. Our related policy and procedure emphasizes applying the criteria for utilization management decision-making based on case-by-case need, and considering an assessment of the availability of services in the local delivery system.

The Medical Necessity Criteria is reviewed on an annual basis and was most recently reviewed and approved for continued use by our Behavioral Quality Committee in March 2024. At that time, there were no behavioral health related changes identified.

Additional information

We encourage your review and consideration of the guidelines as a helpful tool in the delivery of effective care for patients with Evernorth Behavioral Health coverage. If you have any questions or have feedback, please contact Provider Services at 800.926.2273, or send an email to behprep@evernorth.com.

You can find our medical necessity guidance on the Evernorth Provider portal at Provider.Evernorth.com (Review Coverage Policies > Supporting Websites).

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