Non-Quantitative Treatment Limitation (NQTL) violations occur when payers apply more restrictive prior authorization requirements, clinical criteria, or step therapy protocols to behavioral health services than to comparable medical/surgical services. This is a federal MHPAEA violation category with strong enforcement precedent and high appeal success rates.

LOC denials occur when a payer refuses to authorize or continue a specific level of care (inpatient, residential, PHP, IOP, outpatient) claiming the patient's clinical needs do not meet the criteria for that level. Three sub-types require distinct documentation strategies: LOC Initiation (initial auth denied), Step-Down Failure (payer demands step-down before clinical stability), and Continued Stay (ongoing auth denied for active treatment episode).

Substance Use Disorder (SUD) medical necessity denials specifically require ASAM criteria documentation — the American Society of Addiction Medicine multidimensional assessment framework. These denials differ from general medical necessity denials in that payers use ASAM as the accepted clinical standard, and appeals that do not reference ASAM dimensions explicitly have significantly lower success rates.

A distinct sub-category of documentation denials: denials that result from preventable administrative failures rather than genuine clinical insufficiency. These include missing LOCUS forms not submitted with the claim, progress notes not attached, and outdated clinical assessments cited instead of current records. The existing DOC-001 playbook addresses post-denial recovery — this pattern addresses prevention.

Phantom network denials occur when a payer claims in-network BH providers are available, but the listed providers are not actually reachable — wrong phone numbers, full panels, no longer practicing, or not accepting the patient's specific plan. When a patient receives services OON because in-network providers are effectively inaccessible, the payer cannot deny at OON rates — this is a network adequacy violation.

The corpus currently does not capture the service timeline dimension for denials — specifically whether a denial occurred before (pre-service) or after (post-service) care was delivered. This matters because appeal strategies differ substantially between the two: pre-service denials can trigger urgent/concurrent review rights, while post-service denials must meet substantive criteria for retroactive authorization. Adding denial_stage as a corpus dimension enables this stratification.

Payer failed to engage in "meaningful dialogue" as required by ERISA during the claims and appeals process. Four federal circuit court cases (10th Cir. 2023 ×2, 5th Cir. 2024, D. Utah 2025) establish this as a usable procedural reversal path against UHC/UBH regardless of the underlying clinical merit. This argument fires in parallel with clinical appeals — not as an alternative.

Sub-type of NQTL Parity Violation (KB-PATTERN-001) representing a specific enforcement track. BH-specific step therapy requirements are a per se MHPAEA violation per Colorado DOL guidance, and a Taft-Hartley settlement in Pennsylvania established the same principle for self-funded plans. Appeal argument: "No comparable step therapy requirement exists for medical inpatient."

A 2-part evidence gate pattern currently misclassified under Benefit Limit / Frequency in the corpus. Requires two specific documentation elements to successfully overturn: (1) acuity_justification and (2) failure_to_respond documentation. Volume signal: 8.5M denials nationally PY2025 in this category per TC-PUF data.

A distinct denial type that requires a different reversal path from Benefit Exclusion denials. Reversal requires two specific elements: peer-reviewed clinical literature establishing the service as medically accepted and a specialist authority statement supporting the specific treatment. National volume: 11M PY2025 in the "Services Excluded" TC-PUF category.

Payer denies continued residential or inpatient care on the grounds that the patient is improving. The legal and clinical standard is settled: improvement during treatment does not equal "no longer medically necessary." A federal judge found a CA insurer unreasonably ignored medical evidence and misapplied improvement as a basis for denying continued care (CA DMHC precedent). Critical for active residential continued-stay denials.

The network exists on paper but is structurally inadequate because BH reimbursement rates are too low to recruit or retain providers. The appeal argument shifts from directory accuracy to rate structure: the reimbursement rate differential itself is the NQTL — not individual directory errors. This is distinct from last week's Phantom Network pattern (KB-PATTERN-005), which focuses on inaccessible listed providers.

Pediatric-specific network adequacy disparity: standards for BH access are materially lower than for medical/surgical, creating a parity violation at the population level. Florida data: 85–90% pediatric BH access goal vs. 95% pediatric M/S access goal. Michigan data: 95% M/S within 10 miles vs. 85% BH within 30 miles — a 20-mile additional travel requirement for BH care. Sub-type of Network patterns, pediatric-specific.