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HER MENTAL HEALTH TREATMENT WAS HELPING. THAT’S WHY INSURANCE CUT
OFF HER COVERAGE.  
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Maya Miller and Duaa Eldeib
December 31, 2024
ProPublica
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_ Insurers use a patient’s improvement to justify denying mental
health coverage which, in some cases, can cause dangerous, or even
fatal, backslides. _

“I was starting to get to the point where I did have some hope, and
I was like, maybe I can see an actual end to this,” Geneva Moore
said in a recent interview. “And it was just cut off
prematurely.”, Credit:Ilana Panich-Linsman

 

Geneva Moore’s therapist pulled out her spiral notebook. At the top
of the page, she jotted down the date, Jan. 30, 2024, Moore’s
initials and the name of the doctor from the insurance company to whom
she’d be making her case.

She had only one chance to persuade him, and by extension Blue Cross
and Blue Shield of Texas, to continue covering intensive outpatient
care for Moore, a patient she had come to know well over the past few
months.

The therapist, who spoke on the condition of anonymity out of fear of
retaliation from insurers, spent the next three hours cramming, as if
she were studying for a big exam. She combed through Moore’s weekly
suicide and depression assessments, group therapy notes and write-ups
from their past few sessions together.

She filled two pages with her notes: Moore had suicidal thoughts
almost every day and a plan for how she would take her own life. Even
though she expressed a desire to stop cutting her wrists, she still
did as often as three times a week to feel the release of pain. She
only had a small group of family and friends to offer support. And she
was just beginning to deal with her grief and trauma over sexual and
emotional abuse, but she had no healthy coping skills.

Less than two weeks earlier, the therapist’s supervisor had struck
out with another BCBS doctor. During that call, the insurance company
psychiatrist concluded Moore had shown enough improvement that she no
longer needed intensive treatment. “You have made progress,” the
denial letter from BCBS Texas read.

Moore’s denial letter from Blue Cross and Blue Shield of Texas
contradicts many of her therapist’s assessments. Credit:Obtained
and highlighted by ProPublica

When the therapist finally got on the phone with a second insurance
company doctor, she spoke as fast as she could to get across as many
of her points as possible.

“The biggest concern was the abnormal thoughts — the suicidal
ideation, self-harm urges — and extensive trauma history,” the
therapist recalled in an interview with ProPublica. “I was really
trying to emphasize that those urges were present, and they were
consistent.”

She told the company doctor that if Moore could continue on her
treatment plan, she would likely be able to leave the program in 10
weeks. If not, her recovery could be derailed.

The doctor wasn’t convinced. He told the therapist that he would be
upholding the initial denial. Internal notes from the BCBS Texas
doctors say that Moore exhibited “an absence of suicidal
thoughts,” her symptoms had “stabilized” and she could
“participate in a lower level of care.”

The call lasted just seven minutes.

Moore was sitting in her car during her lunch break when her therapist
called to give her the news. She was shocked and had to pull herself
together to resume her shift as a technician at a veterinary clinic.

“The fact that it was effective immediately,” Moore said later,
“I think that was the hardest blow of it all.”

After BCBS Texas denied Moore’s treatment, her therapist, pictured
here, urged the company to reconsider. Credit:Ilana Panich-Linsman,
special to ProPublica

Many Americans must rely on insurers when they or family members are
in need of higher-touch mental health treatment, such as intensive
outpatient programs or round-the-clock care in a residential facility.
The costs are high, and the stakes for patients often are, too. In
2019 alone, the U.S. spent more than $106.5 billion treating adults
with mental illness
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which private insurance paid about a third. One 2024 study
[[link removed]] found
that the average quoted cost for a month at a residential addiction
treatment facility for adolescents was more than $26,000.

Health insurers frequently review patients’ progress to see if they
can be moved down to a lower — and almost always cheaper — level
of care. That can cut both ways. They sometimes cite a lack of
progress as a reason to deny coverage, labeling patients’ conditions
as chronic and asserting that they have reached their baseline level
of functioning. And if they make progress, which would normally be
celebrated, insurers have used that against patients to argue they no
longer need the care being provided.

Their doctors are left to walk a tightrope trying to convince insurers
that patients are making enough progress to stay in treatment as long
as they actually need it, but not so much that the companies
prematurely cut them off from care. And when insurers demand that
providers spend their time justifying care, it takes them away from
their patients.

“The issues that we grapple with are in the real world,” said Dr.
Robert Trestman, the chair of psychiatry and behavioral medicine at
the Virginia Tech Carilion School of Medicine and chair of the
American Psychiatric Association’s Council on Healthcare Systems and
Financing. “People are sicker with more complex conditions.”

Mental health care can be particularly prone to these progress-based
denials. While certain tests reveal when cancer cells are no longer
present and X-rays show when bones have healed, psychiatrists say they
have to determine whether someone has returned to a certain level of
functioning before they can end or change their treatment. That can be
particularly tricky when dealing with mental illness, which can be
fluid, with a patient improving slightly one day only to worsen the
next.

Though there is no way to know how often coverage gets cut off
mid-treatment
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ProPublica has found scores of lawsuits over the past decade in which
judges have sharply criticized insurance companies for citing a
patient’s improvement to deny mental health coverage. In a number of
those cases, federal courts ruled that the insurance companies had
broken a federal law
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to provide protections for people who get health insurance through
their jobs.

Reporters reviewed thousands of pages of court documents and
interviewed more than 50 insiders, lawyers, patients and providers.
Over and over, people said these denials can lead to real —
sometimes devastating — harm. An official at an Illinois facility
with intensive mental health programs said that this past year, two
patients who left before their clinicians felt they were ready due to
insurance denials had attempted suicide.

Dr. Eric Plakun, a Massachusetts psychiatrist with more than 40 years
of experience in residential and intensive outpatient programs, and a
former board member of the American Psychiatric Association, said the
“proprietary standards” insurers use as a basis for denying
coverage often simply stabilize patients in crisis and “shortcut
real treatment.”

Plakun offered an analogy: If someone’s house is on fire, he said,
putting out the fire doesn’t restore the house. “I got a hole in
the roof, and the windows have been smashed in, and all the furniture
is charred, and nothing’s working electrically,” he said. “How
do we achieve recovery? How do we get back to living in that home?”

Unable to pay the $350-a-day out-of-pocket cost for additional
intensive outpatient treatment, Moore left her program within a week
of BCBS Texas’ denial. The insurer would only cover outpatient talk
therapy.

During her final day at the program, records show, Moore’s suicidal
thoughts and intent to carry them out had escalated from a 7 to a 10
on a 1-to-10 scale. She was barely eating or sleeping.

A few hours after the session, Moore drove herself to a hospital and
was admitted to the emergency room, accelerating a downward spiral
that would eventually cost the insurer tens of thousands of dollars,
more than the cost of the treatment she initially requested.

Moore’s wrists still show scars from where she was cutting
herself. Credit:Ilana Panich-Linsman, special to ProPublica

How Insurers Justify Denials

Buried in the denial letters that insurance companies send patients
are a variety of expressions that convey the same idea: Improvement is
a reason to deny coverage.

“You are better.” “Your child has made progress.” “You have
improved.”

In one instance, a doctor working for Regence Blue Cross and Blue
Shield of Oregon wrote that a patient who had been diagnosed with
major depression was “sufficiently stable,” even as her own
doctors wrote that she “continued to display a pattern of severe
impairment” and needed round-the-clock care. A judge ruled that “a
preponderance of the evidence” demonstrated that the teen’s
continued residential treatment was medically necessary. The insurer
said it can’t comment on the case because it ended with a
confidential settlement.

In another, a doctor working for UnitedHealth Group wrote in 2019 that
a teenage girl with a history of major depression who had been
hospitalized after trying to take her own life by overdosing “was
doing better.” The insurer denied ongoing coverage at a residential
treatment facility. A judge ruled that the insurer’s determination
“lacked any reasoning or citations” from the girl’s medical
records and found that the insurer violated federal law. United did
not comment on this case but previously argued that the girl no longer
had “concerning medical issues” and didn’t need treatment in a
24-hour monitored setting.

To justify denials, the insurers cite guidelines that they use to
determine how well a patient is doing and, ultimately, whether to
continue paying for care. Companies, including United, have said these
guidelines are independent, widely accepted and evidence-based.

Insurers most often turn to two sets: MCG (formerly known as Milliman
Care Guidelines), developed by a division of the multibillion-dollar
media and information company Hearst, and InterQual, produced by a
unit of UnitedHealth’s mental health division, Optum. Insurers have
also used guidelines they have developed themselves.

MCG Health did not respond to multiple requests for comment. A
spokesperson for the Optum division that works on the InterQual
guidelines said that the criteria “is a collection of established
scientific evidence and medical practice intended for use as a first
level screening tool” and “helps to move patients safely and
efficiently through the continuum of care.”

A separate spokesperson for Optum also said the company’s
“priority is ensuring the people we serve receive safe and effective
care for their individual needs.” A Regence spokesperson said that
the company does “not make coverage decisions based on cost or
length of stay,” and that its “number one priority is to ensure
our members have access to the care they need when they need it.”

In interviews, several current and former insurance employees from
multiple companies said that they were required to prioritize the
proprietary guidelines their company used, even if their own clinical
judgment pointed in the opposite direction.

“It’s very hard when you come up against all these rules that are
kind of setting you up to fail the patient,” said Brittainy Lindsey,
a licensed mental health counselor who worked at the Anthem subsidiary
Beacon and at Humana for a total of six years before leaving the
industry in 2022. In her role, Lindsey said, she would suggest
approving or denying coverage, which — for the latter — required a
staff doctor’s sign-off. She is now a mental health consultant for
behavioral health businesses and clinicians.

A spokesperson for Elevance Health, formerly known as Anthem, said
Lindsey’s “recollection is inaccurate, both in terms of the
processes that were in place when she was a Beacon employee, and how
we operate today.” The spokesperson said “clinical judgment by a
physician — which Ms. Lindsey was not — always takes precedence
over guidelines.”

In an emailed statement, a Humana spokesperson said the company’s
clinician reviewers “are essential to evaluating the facts and
circumstances of each case.” But, the spokesperson said, “having
objective criteria is also important to provide checks and balances
and consistently comply with” federal requirements.

The guidelines are a pillar of the health insurance system known as
utilization management, which paves the way for coverage denials. The
process involves reviewing patients’ cases against relevant criteria
every handful of days or so to assess if the company will continue
paying for treatment, requiring providers and patients to repeatedly
defend the need for ongoing care.

Federal judges have criticized insurance company doctors for using
such guidelines in cases where they were not actually relevant to the
treatment being requested
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for “solely” basing their decisions on them
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Wit v. United Behavioral Health
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a class-action lawsuit involving a subsidiary of UnitedHealth, has
become one of the most consequential mental health cases of this
century. In that case, a federal judge in California concluded
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a number of United’s in-house guidelines did not adhere to generally
accepted standards of care. The judge found that the guidelines
allowed the company to wrongly deny coverage for certain mental health
and substance use services the moment patients’ immediate problems
improved. He ruled that the insurer would need to change its
practices. United appealed the ruling on grounds other than the
court’s findings about the defects in its guidelines, and a panel of
judges partially upheld the decision. The case has been sent back to
the district court for further proceedings.

Largely in response to the Wit case, nine states
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passed laws requiring health insurers to use guidelines that align
with the leading standards of mental health care, like those developed
by nonprofit professional organizations.

Cigna has said
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it “has chosen not to adopt private, proprietary medical necessity
criteria” like MCG. But, according to a review of lawsuits, denial
letters have continued to reference MCG. One federal judge in Utah
called out the company, writing that Cigna doctors
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the claims under medical necessity guidelines it had disavowed.”
Cigna did not respond to specific questions about this.

Timothy Stock, one of the BCBS doctors who denied Moore’s request to
cover ongoing care, had cited MCG guidelines when determining she had
improved enough — something judges noted he had done before. In
2016, Stock upheld a decision on appeal to deny continued coverage for
a teenage girl who was in residential treatment for major depression,
post-traumatic stress disorder and anxiety. Pointing to the
guidelines, Stock concluded she had shown enough improvement.

The patient’s family sued the insurer, alleging it had wrongly
denied coverage. Blue Cross and Blue Shield of Illinois argued that
there was evidence that showed the patient had been improving. But, a
federal judge found the insurer misstated its significance. The judge
partially ruled in the family’s favor, zeroing in on Stock and
another BCBS doctor’s use of improvement to recommend denying
additional care.

“The mere incidence of some improvement does not mean treatment was
no longer medically necessary,” the Illinois judge wrote
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In another case
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BCBS Illinois denied coverage for a girl with a long history of mental
illness just a few weeks into her stay at a residential treatment
facility, noting that she was “making progressive improvements.”
Stock upheld the denial after an appeal.

Less than two weeks after Stock’s decision, court records show, she
cut herself on the arm and leg with a broken light bulb. The insurer
defended the company’s reasoning by noting that the girl
“consistently denied suicidal ideation,” but a judge wrote that
medical records show the girl was “not forthcoming” with her
doctors about her behaviors. The judge ruled against the insurer,
writing that Stock and another BCBS doctor “unreasonably ignored the
weight of the medical evidence” showing that the girl required
residential treatment.

Stock declined to comment. A spokesperson for BCBS said the
company’s doctors who review requests for mental health coverage are
board certified psychiatrists with multiple years of practice
experience. The spokesperson added that the psychiatrists review all
information received “from the provider, program and members to
ensure members are receiving benefits for the right care, at the right
place and at the right time.”

The BCBS spokesperson did not address specific questions related to
Moore or Stock. The spokesperson said that the examples ProPublica
asked about “are not indicative of the experience of the vast
majority of our members,” and that it is committed to providing
“access to quality, cost-effective physical and behavioral health
care.”

A Lifelong Struggle

A former contemporary dancer with a bright smile and infectious laugh,
Moore’s love of animals is eclipsed only by her affinity for plants.
She moved from Indiana to Austin, Texas, about six years ago and
started as a receptionist at a clinic before working her way up to
technician.

Moore’s depression has been a constant in her life. It began as a
child, when, she said, she was sexually and emotionally abused. She
was able to manage as she grew up, getting through high school and
attending Indiana University. But, she said, she fell back into a deep
sadness after she learned in 2022 that the church she found comfort in
as a college student turned out to be what she and others deemed a
cult. In September of last year, she began an intensive outpatient
program, which included multiple group and individual therapy sessions
every week.

Moore, 32, had spent much of the past eight months in treatment for
severe depression, post-traumatic stress disorder and anxiety when
BCBS said it would no longer pay for the program in January.

The denial had come to her without warning.

“I was starting to get to the point where I did have some hope, and
I was like, maybe I can see an actual end to this,” Moore said.
“And it was just cut off prematurely.”

At the Austin emergency room where she drove herself after her
treatment stopped, her heart raced. She was given medication as a
sedative for her anxiety. According to hospital records she provided
to ProPublica, Moore’s symptoms were brought on after “insurance
said they would no longer pay.”

A hospital social worker frantically tried to get her back into the
intensive outpatient program.

“That’s the sad thing,” said Kandyce Walker, the program’s
director of nursing and chief operating officer, who initially argued
Moore’s case with BCBS Texas. “To have her go from doing a little
bit better to ‘I’m going to kill myself.’ It is so frustrating,
and it’s heartbreaking.”

After the denial and her brief admission to the hospital emergency
department in January, Moore began slicing her wrists more frequently,
sometimes twice a day. She began to down six to seven glasses of wine
a night.

“I really had thought and hoped that with the amount of work I’d
put in, that I at least would have had some fumes to run on,” she
said.

She felt embarrassed when she realized she had nothing to show for
months of treatment. The skills she’d just begun to practice seemed
to disappear under the weight of her despair. She considered going
into debt to cover the cost of ongoing treatment but began to think
that she’d rather end her life.

“In my mind,” she said, “that was the most practical thing to
do.”

Whenever the thought crossed her mind — and it usually did multiple
times a day — she remembered that she had promised her therapist
that she wouldn’t.

Moore’s therapist encouraged her to continue calling BCBS Texas to
try to restore coverage for more intensive treatment. In late
February, about five weeks after Stock’s denial, records show that
the company approved a request that sent her back to the same facility
and at the same level of care as before.

But by that time, her condition had deteriorated so severely that it
wasn’t enough.

Eight days later, Moore was admitted to a psychiatric hospital about
half an hour from Austin. Medical records paint a harrowing picture of
her condition. She had a plan to overdose and the medicine to do it.
The doctor wrote that she required monitoring and had “substantial
ongoing suicidality.” The denial continued to torment her. She told
her doctor that her condition worsened after “insurance stopped
covering” her treatment.

Her few weeks stay at the psychiatric hospital cost $38,945.06. The
remaining 10 weeks of treatment at the intensive outpatient program
— the treatment BCBS denied — would have cost about $10,000.

Bracelets and a watch cover Moore’s scars from cutting
herself. Credit:Ilana Panich-Linsman, special to ProPublica

Moore was discharged from the hospital in March and went back into the
program Stock had initially said she no longer needed.

It marked the third time she was admitted to the intensive outpatient
program.

A few months later, as Moore picked at her lunch, her oversized
glasses sliding down the bridge of her nose every so often, she
wrestled with another painful realization. Had the BCBS doctors not
issued the denial, she probably would have completed her treatment by
now.

“I was really looking forward to that,” Moore said softly. As she
spoke, she played with the thick stack of bracelets hiding the scars
on her wrists.

A few weeks later, that small facility closed in part because of
delays and denials from insurance companies, according to staff and
billing records. Moore found herself calling around to treatment
facilities to see which ones would accept her insurance. She finally
found one, but in October, her depression had become so severe that
she needed to be stepped up to a higher level of care.

Moore was able to get a leave of absence from work to attend
treatment, which she worried would affect the promotion she had been
working toward. To tide her over until she could go back to work, she
used up the money her mother sent for her 30th birthday.

She smiles less than she did even a few months ago. When her roommates
ask her to hang out downstairs, she usually declines. She has taken
some steps forward, though. She stopped drinking and cutting her
wrists, allowing scar tissue to cover her wounds.

But she’s still grieving what the denial took from her.

“I believed I could get better,” she said recently, her voice
shaking. “With just a little more time, I could discharge, and I
could live life finally.”

_Maya Miller is an engagement reporter at ProPublica working on
community-sourced investigations.  Duaa Eldeib is a reporter at
ProPublica whose work has examined the systemic failures that led to
a stillbirth crisis
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fatal
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of delaying care during the pandemic
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the plight of hundreds of children trapped in psychiatric hospitals
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* mental health
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* health-care coverage
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* denial of care
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