{"id":170099,"date":"2025-09-26T07:10:10","date_gmt":"2025-09-26T07:10:10","guid":{"rendered":"https:\/\/www.newsbeep.com\/ca\/170099\/"},"modified":"2025-09-26T07:10:10","modified_gmt":"2025-09-26T07:10:10","slug":"their-son-was-too-unstable-to-function-outside-of-hospital-insurance-denied-his-mental-health-treatment-anyway","status":"publish","type":"post","link":"https:\/\/www.newsbeep.com\/ca\/170099\/","title":{"rendered":"Their son was ‘too unstable to function outside of hospital.’ Insurance denied his mental health treatment anyway."},"content":{"rendered":"

NBC News reached out to Quantum Health with a list of questions about Johnathan\u2019s case. In response, a Quantum Health spokesperson said in a statement, \u201cQuantum Health is not an insurer, insurance company or provider. We provide healthcare navigation and care coordination services to members on behalf of their employer\u2019s health and welfare benefits program.\u201d<\/p>\n

\u201cDeterminations are solely based on current policy parameters regarding a member\u2019s coverage under the specific Plan and are not a reflection of the value of the care requested care or a treatment decision,\u201d the spokesperson wrote in an email.<\/p>\n

In the denial letters from Quantum Health, the company writes that the details of Johnathan\u2019s case were \u201creviewed against the plan document and the utilization criteria adopted by the plan.\u201d<\/p>\n

\u201cUtilization criteria\u201d refers to internal guidelines used by insurers to assess how well a patient is doing and to decide whether to cover care. <\/p>\n

\u201cSo many are self-generated by each company and are essentially a black box because we outside don\u2019t know what they are,\u201d Trestman said. \u201cIt\u2019s playing with a stacked deck of cards where the dealer is the insurer, and they control literally everything, because even the internal appeals process is inside their company.\u201d <\/p>\n

If you are dealing with bills that seem to be out of line or a denial of coverage, care or repairs, whether for health, home or auto, please email us at Costofdenial@nbcuni.com.<\/a><\/p>\n

According to insurance documents reviewed by NBC News, the Benz-Bushlings\u2019 insurance plan uses a set of guidelines called InterQual that are produced by Optum, a division of UnitedHealthcare. In an issue brief dated 2025, the American Medical Association classified the InterQual guidelines as \u201cproprietary, financially-driven criteria.\u201d<\/p>\n

\u201cThese criteria often lead to delayed care through prior authorization and denied care through other financially driven, profit-based motives,\u201d the AMA brief says. <\/p>\n

In its statement to NBC News, Quantum said \u201cWhen reviewing requests for behavioral health services, we are obligated to follow the terms of the specific Plan, including its rules for \u2018medical necessity\u2019 and \u2018appropriate level of care\u2019 based on nationally recognized criteria, such as InterQual and Locus.\u201d<\/p>\n

\u201cInterQual Criteria are objective and specific, helping guide consistent, defensible decisions that ensure appropriate, quality care,\u201d Optum\u2019s website says<\/a>, describing the guidelines as a \u201crigorous, evidence-based development process.\u201d<\/p>\n

The Benz-Bushlings appealed Quantum\u2019s decision three times. Each time, they were denied. <\/p>\n

\"NickNick Benz-Bushling doles out Johnathan’s medications. Nick and Misty Benz-Bushling still keep all alcohol and medicines locked in their bedroom. Alfield Reeves for NBC News<\/p>\n

Before the final denial, Quantum routed their appeal to an outside company called AllMed Healthcare Management, which it hired to conduct an independent review. AllMed upheld the denial, arguing that Johnathan had made progress over the course of his treatment and was no longer experiencing suicidal ideation. The letter found that he was \u201clargely compliant with his treatment plan.\u201d<\/p>\n

According to Trestman, signs that a treatment is working can be grounds for insurers to move patients to a lower level of care \u2014 but he cautioned that because mental health is fluid, ending treatment too early can cause a patient\u2019s progress to backslide. <\/p>\n

\u201cWhen we document in a chart, we\u2019re trying to reflect that the care we\u2019re providing is helping and looking for positive change, but that doesn\u2019t mean that it\u2019s going to stick. That doesn\u2019t mean that it\u2019s going to persist, or that it\u2019s something that should justify reducing the level of care,\u201d he said. <\/p>\n

A 270-page appeal<\/p>\n

Before that final denial, the Benz-Bushlings had assembled a 270-page appeal document that illustrated Johnathan\u2019s years of mental health struggles. His depression<\/a> first became noticeable in 2022, when he started to withdraw from family life and began vaping marijuana almost constantly. As he entered high school, his addiction issues became more serious. <\/p>\n

\u201cIt got to the point where he had to be escorted everywhere that he went,\u201d Benz-Bushling said. \u201cHe was never supposed to be alone. He was still finding ways to get THC vapes into our house, and he couldn\u2019t get through a school day without getting high.\u201d<\/p>\n

To get their son away from friends who they said supplied him with drugs and alcohol, they decided to pack up their home in Virginia and move to Michigan earlier this year. <\/p>\n

While still in Virginia, Johnathan had done therapy, intensive outpatient treatment and one earlier stint at a residential facility. When the family arrived in Michigan, they thought it was a fresh start. <\/p>\n","protected":false},"excerpt":{"rendered":"NBC News reached out to Quantum Health with a list of questions about Johnathan\u2019s case. In response, a…\n","protected":false},"author":2,"featured_media":170100,"comment_status":"","ping_status":"","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[35],"tags":[49,48,84,393,394],"class_list":{"0":"post-170099","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-mental-health","8":"tag-ca","9":"tag-canada","10":"tag-health","11":"tag-mental-health","12":"tag-mentalhealth"},"_links":{"self":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/170099","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/comments?post=170099"}],"version-history":[{"count":0,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/posts\/170099\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media\/170100"}],"wp:attachment":[{"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/media?parent=170099"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/categories?post=170099"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.newsbeep.com\/ca\/wp-json\/wp\/v2\/tags?post=170099"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}