Key Takeaways:

• A man in North Carolina faced an insurance denial for crucial mental health treatment after two suicide attempts.
• His wife fought back, appealed internal denials, and sought a rare external review.
• An independent psychiatrist reviewer overruled the insurer’s claim of “not medically necessary.”
• Insurance denials leave many patients paying tens of thousands of dollars or dropping care.

UNDERSTANDING INSURANCE DENIAL AND APPEALS

Insurance denial happens when an insurer refuses to pay for a treatment it once preapproved. In this case, Highmark Blue Cross Blue Shield said a monthlong stay at a psychiatric hospital was “not medically necessary.” The insurer had even confirmed pre-authorization weeks earlier. When a claim faces an insurance denial, patients can appeal inside their plan. Then they can ask for an external review by an independent doctor. However, fewer than 1 in 10,000 people even file for that extra review.

THE REAL STORY BEHIND ONE COUPLE’S FIGHT

A software engineer known here as “L” began suffering grave anxiety in early 2023. He and his wife, Teressa, had just bought a ranch home near Raleigh. When the remodel and rental of their old house ran over budget, his panic attacks grew worse. After two suicide attempts in February, a judge ordered him into a mental health center. Later, he moved to a residential program, then a top psychiatric clinic in Houston. Yet each stay triggered a barrage of denials from Highmark. It labeled the care “not medically necessary” under mental health rules.

STEPS IN THE EXTERNAL REVIEW PROCESS

First, a patient must file internal appeals with the insurer. If that fails, they can ask for an external review. State or federal laws govern eligibility and deadlines. Then the insurer picks a review company. That company hires a doctor to recheck the medical facts. In 2024, Dr. Neal Goldenberg, a community psychiatrist, got Teressa’s appeal. He read 200 pages of records, studies on suicidal thoughts, and letters from two psychiatrists. He found the denial deeply unfair. Then he did something he had never done in six years: he called Teressa.

HOW AN INDEPENDENT DOCTOR OVERRULED AN INSURER

Dr. Goldenberg learned in medical school to fight for patients. As an external reviewer, he holds insurers to binding decisions. After an hour and a half of study, he sided with the family. He wrote that Highmark failed to grasp L’s complex medical and psychiatric needs. The insurer had paused treatment for a colon infection and then treated the new care as a fresh admission. Goldenberg pointed out that resuming therapy after a crisis was vital. He found their plan “unfairly denied” as not medically necessary. Highmark had to pay.

THE HIGH PRICE OF INSURANCE DENIAL

L’s full treatment cost more than $220,000. Because of initial denials, the couple paid over $95,000 out of pocket. Many Americans lack that cushion. They skip care, dig into debt, or give up entirely. After the external review, Highmark reimbursed more than $70,000. Even so, the fight drained the couple’s savings. They also faced broken promises, lost records, and repeated billing errors. Once, a denial for a colon emergency described L as a newborn. That showed how little the insurer seemed to read their case.

HOW TO FIGHT BACK AGAINST INSURANCE DENIAL

If you face a similar battle, start by reading your plan’s fine print. Note appeal deadlines. Track every call, email, and letter. Use a clear system of folders or file boxes. Get doctors to write detailed notes on medical necessity. If internal appeals fail, request an external review. State or federal law should let you do it, so long as your plan covers the issue. Remember that outside reviewers like Dr. Goldenberg can force insurers to pay. Yet most patients never take this final step.

NOW THEY’RE REBUILDING THEIR LIVES

Today, Teressa and L live in separate houses but still share meals and support each other. He returned to work without explaining his ordeal to colleagues. He jokes and laughs, though the small scar on his neck reminds him of the darkest days. She attends couple’s therapy and processes her own trauma. Both know they were lucky to find an external reviewer who listened. Dr. Goldenberg says he took the job to add humanity to a broken system. He urges all doctors to support patients in appeals.

CONCLUSION

Insurance denial in mental health can block critical care when people are at their weakest. Yet external reviews offer a lifeline. Independent doctors can enforce binding decisions and hold insurers accountable. Although the appeal rate remains tiny, stories like this show the power of persistence. Patients and families should know their rights and keep fighting.

FAQs

What is an external review of an insurance denial?

An external review is when an independent doctor rechecks an insurer’s decision. Their ruling is binding on the insurance company.

How common is it to win an appeal after an insurance denial?

Winning an internal appeal varies, but fewer than 1 in 10,000 people seek external review. Those who do often succeed.

What counts as “medically necessary” in mental health care?

Medical necessity means treatment fits accepted standards for a patient’s condition. Detailed clinical notes help prove it.

How can families prepare for an insurance denial fight?

Start by reading the policy, tracking every interaction, keeping medical records, and asking doctors for strong appeal letters.