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, federal or state law require use of other clinical criteria.

In addition to the MCG Behavioral Health Guidelines, the following resources are currently being used to make medical necessity determinations:

• The ASAM Criteria^®
  Evernorth uses this 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, federal or state law require use of other clinical criteria.
• LOCUS and CALOCUS-CASII Criteria
  Evernorth uses 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 or state law require use of other clinical criteria.
  • LOCUS Criteria
  • CALOCUS-CASII Criteria
• Cigna Medical Coverage Policies
• Evernorth Authorization and Billing Resource
• State regulations and licensing standards¹

For more information about all of the resources listed above, visit the Coverage Policies page on this website and see Supporting Behavioral Websites.

Archived criteria*

• Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders (Revised April 2020)
• Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders (Revised January 2020)
• Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders (Revised January 2019)

For regulatory and reference purposes, applicable versions of our former Standards and Guidelines/Medical Necessity Criteria for Treatment of Mental Health Disorders will be used throughout the duration of cases that were submitted prior November 27, 2020. These cases include:

• Prior authorization requests
• Continued care requests/concurrent reviews
• Appeals where the Cigna document is used in initial determinations

¹ Evernorth complies with state specific laws, as written.