California families battling addiction fight for their lives after insurance denials

Christine Dougherty heard the panic in her son's voice.

"Mom, they're going to release me soon," Ryan Matlock told his mother over the phone from his addiction treatment center. She remembered him sounding like he was crying. "I'm not strong enough to do this. I need help."

At 23 years old, Matlock had already overdosed at least once on fentanyl. In this quiet Southern California community dotted with soccer fields and American flags, little blue pills laced with the highly addictive drug were easy enough to obtain.

Desperate to save himself, Matlock had begged his health insurance plan to place him in a Palm Desert residential treatment facility that knew how to handle fentanyl addiction.

But three days after he arrived at Pacifica Recovery, Matlock's counselor relayed devastating news. Over the entreaties of his doctor and mother, a psychiatrist reviewing his case on behalf of his health plan had decided Matlock didn't need to stay there any longer, health records show.

No one at Optum ever spoke with Matlock himself, his mother said.

On the evening of Saturday March 20, 2021, Matlock's older sister, Haley, said she picked him up and drove him home.

That Tuesday morning, she knocked on his bedroom door.

By the time paramedics arrived 14 minutes later, the 911 operator had already instructed Haley to stop doing chest compressions.

How big is the problem?

Did a health plan's refusal to authorize further treatment help cause Ryan Matlock's death?

That question is at the heart of a wrongful death lawsuit brought by Matlock's mother against U.S. Behavioral Health Plan of California, which does business with the public as OptumHealth Behavioral Solutions of California. Dougherty alleges her health plan disregarded her son's safety; representatives of the plan insist it always adheres to clinical guidelines and follows the law.

California passed landmark mental health coverage legislation in 2020, requiring plans to provide their enrollees with all medically necessary mental health and addiction treatment. But to people enduring the darkest moments of their lives, the separation between what that law requires and what health plans provide often feels like a gaping chasm. In recent years, a variety of potential fixes that would require more accountability from plans have come before state lawmakers; most have failed.

In the meantime, the system for appealing mental health denials effectively remains broken, a CalMatters investigation found:

Research shows most people who receive treatment authorization denials don't appeal to their health plans; advocates say the fraction who do so often end up being denied yet again by reviewers who are not formally trained in using the decision-making criteria required under state law.Generally speaking, a few doctors, working on behalf of health plans, appear to deny almost every appeal for behavioral health treatment they review, according to data from one medical billing company about treatment facilities around the country.Regulators don't have data to track these reviewers' decisions. Neither the state's Department of Managed Health Care nor the California Department of Insurance is authorized by state statute to routinely require health plans and health insurers to submit information about how often they deny treatment, nor do they have access to the records of the individual doctors making these denials.When state regulators do get involved, they overwhelmingly side with patients. For 2023 and the first eight months of 2024, for appeals related to residential treatment denials, the Department of Managed Health Care overturned health plans' medical necessity decisions a stunning 76% of the time.

Mary Watanabe, the department's director, called such high overturn rates "concerning."

"I think it's an indication that it warrants further research and looking into it," she said.

Health plan representatives push back against allegations that they are unfairly denying mental health and addiction treatment.

Mary Ellen Grant, spokesperson for the California Association of Health Plans, said in an email that plans "strictly adhere" to the new state mental health parity law.

"Oftentimes claims that are 'denied' by a health plan are due to paperwork errors and often patients get the care they need with no financial impact," she wrote. "Claims can be returned for a number of reasons that ultimately have no impact on a patient's care or require the patient to pay for a health care service."

More than 50 patients, family members, clinicians, attorneys and advocates described a different reality to CalMatters.

Several clinicians said they sometimes have to tell patients who they worry are at risk of self-harm that their health plans won't pay for further treatment. That leaves providers navigating fraught legal and ethical terrain: Staying in a hospital or treatment facility after an insurance denial could burden patients with thousands of dollars of medical debt; leaving could kill them.

"That's the hardest part, to say to someone 'Do you want to risk it? How much are you thinking you might kill yourself?" said Dr. Alexis Seegan, inpatient medical director at the UC Irvine Medical Center and immediate past chairperson of the government affairs committee of the California State Association of Psychiatrists.

"What if they end their lives or really hurt themselves? It's an easy risk for an insurance company, but these are real people. That's a huge risk for them and their families to take."

Ryan Matlock's mother, Christine Dougherty, a first grade teacher in Yucaipa, said she's paid her insurance bill on time every month for decades so that her health plan will take care of her family.

She said she's suing Optum — which handles behavioral health services for United Health — because "I don't feel they did."

Dougherty's lawsuit, which was filed in May 2022 in San Bernardino County Superior Court, alleges that OptumHealth said Matlock could safely leave the residential facility, against Matlock's treating doctors' assessments, "solely to save money and in total disregard of Ryan's health and safety."

The health plan has responded that the case belongs in arbitration; an appeals court agreed, and the case is currently set for arbitration next year.

Attorneys from Gibson, Dunn & Crutcher LLP, the firm representing the health plan, did not respond to repeated calls and emails about the case.

OptumHealth declined to answer any questions about the case or its appeals process for what a spokesperson described as "privacy and legal reasons," although Matlock's family was prepared to waive privacy protections. The company released a brief statement saying the health plan's "coverage determinations are made in accordance with the terms of the member's health plan and federal and state laws, as well as using evidence-based clinical guidelines and peer-to-peer reviews."

Matlock's claim file — the collection of internal records that insurance companies keep about their decisions to reject or deny claims — was provided to CalMatters by Dougherty's attorney, Travis Corby.

Those records show that the fact that Matlock had previously been in another facility and had relapsed was one of several factors in the reviewer's decision to deny.

Dougherty remembers screaming and crying over the phone with her health plan, begging them to let her son stay in treatment longer.

"He wasn't a person," she said. "He was just a number."

Who defines what is medically necessary?

As they seek to balance competing priorities, health plans must answer a key question: Is treatment medically necessary?

California's 2020 mental health coverage law, known as parity, requires that state-regulated plans make such "medical necessity" determinations using specific criteria outlined by nonprofit organizations that specialize in behavioral health. If the criteria indicates that a treatment is medically necessary, the health plan or insurer is then required to cover it. The concept of "parity" refers to requiring health insurers to provide equivalent treatment for mental and physical health conditions.

No one argues that health plans should never bump patients to a lower level of care. Residential facilities can cost as much as thousands of dollars a day — and not everyone needs to be in 24-hour care. Those sizable sums have also at times made the residential care industry ripe for fraud and abuse.

In Matlock's case, criteria to determine medical necessity was laid out under the nonprofit American Society of Addiction Medicine. Since passing the parity law in 2020, the state has required plans to use this criteria to identify what kind of treatment a patient needs. It guides reviewers in evaluating everything from withdrawal symptoms to likelihood of relapse to support at home.

Similar medical necessity criteria exist for eating disorders and other serious mental illnesses.

Patients who are denied treatment authorization generally can first appeal to their health plans; this can involve a review of available records as well as a peer-to-peer review that includes a phone conversation between the patient's clinician and a reviewer working on behalf of the health plan.

But patient advocates and treating physicians say that health plan reviewers don't always have adequate training in how to use the nonprofit criteria, nor do they spend enough time to fairly evaluate cases.

In the absence of comprehensive public data, information provided to CalMatters by one medical billing company provides a valuable, if limited, window into an industry that can often feel like a black box to consumers.

The billing company — which asked not to be named — shared four years of data capturing more than 2,000 appeals by patients requesting mental health treatment around the country.

Per the data, health plan reviewers working with various companies denied the majority of those appeals. But that overall rate masks some acute disparities. While certain reviewers approved the majority of patient appeals they received, others said "no" to every single case they reviewed.

Of 40 identifiable doctors in the data set who conducted the most reviews, CalMatters identified 10 doctors who denied more than 70% of patient appeals; of those, four refused to pay for treatment more than 90% of the time.

Corey Waller, editor-in-chief of the fourth edition of The ASAM Criteria, says health plan reviewers ideally should have a minimum of 16 hours of training in using the criteria. Currently, he says, there's a disconnect between how reviewers interpret the criteria, "and the reality of what it means to apply it to a real person." He also says some of the responsibility for bad decisions lies with treatment providers, who often don't provide health plans with enough documentation to make it easy to make the right decision.

In theory, he says, ASAM criteria could offer the two sides "a common language" to reach a conclusion about medical necessity. In practice, he said, "I think it's really fuzzy."

"Right now it's causing huge amounts of risk for patients who don't get access to care, risk of overdose, risk of relapse, families falling apart, people losing their jobs. Like, just get them into care, man, we'll figure it out later," he said.

Grant, the spokesperson for the California Association of Health Plans, said in an emailed statement that it is impossible to ensure a perfect match in terms of experience for the medical experts reviewing each case on behalf of the plans.

"If an exact peer match was required, the workforce shortfalls alone would create major delays in the appeals process," she said.

Ryan Matlock's search for help

Nestled in the foothills of the San Bernardino Mountains, Yucaipa is a sleepy bedroom community less than an hour's drive from Riverside's suburban sprawl to the west, Palm Springs' tourist resorts to the east and the designer cabins abutting sparkling Lake Arrowhead to the north.

Christine Dougherty lives here with her daughter, Haley, in a 2-story home where they moved after Ryan died. In the front room, she displays a set of meticulously organized scrapbooks full of photos of her children's birthday parties, Halloween costumes and soccer games, their frequent road trips to Disneyland and the beach.

Ryan and Haley's father separated from Dougherty when Ryan was in middle school. After that, the children lived full-time with their mother, although Christine and Haley say the family still spent a lot of time all together.

Ryan Matlock was tall and lanky, with thick brown hair, intense blue eyes and an infectious giggle, "so happy he could talk to a brick wall and make the brick wall smile," his friend Tyler Braden remembers. Even as a little boy, Matlock hated to see anyone sad, his mother said. At the park, he always sought out children playing alone.

Braden first met him at the beginning of third grade at Calimesa Elementary, where Dougherty taught for 29 years. Braden, brand-new to the school, felt nervous until Matlock introduced himself. The two boys became inseparable, playing Call of Duty or Halo after school, hanging out at the skate park or jumping BMX bikes on weekends.

In their teens, they began to experiment, Braden said. A bottle of vodka. A little weed. Later, someone close to Braden gave him pills to blunt pain caused by bulging discs, he said. Matlock wanted to try them. Eventually, Braden realized they were a problem for his friend, he said, and cut Matlock off.

By then, another drug had begun growing in popularity in San Bernardino County, where Yucaipa is located. Fentanyl was a cheap, synthetic opioid that illicit drug makers were increasingly cutting into other drugs — including illegal pain pills.

Fentanyl was far more addictive than heroin, "rewiring brains," said Stuart Cullum, a detective on the county's overdose response team. It was also far more lethal. Some kids died the first time they tried it.

According to recollections of Matlock's mother and sister, he initially bought pain pills laced with fentanyl unwittingly. His medical records show he first used fentanyl in his late teens or early 20s; and that eventually he was smoking or snorting up to 15 pills a day.

As time went by, Christine Dougherty noticed her already slim son getting thinner. He didn't seem quite as happy-go-lucky; he wasn't going out with friends. Something seemed off.

Finally, he told her the truth: "Mom," she remembered him saying, "I need help."

Dougherty and her children were insured by UnitedHealthcare and received behavioral health benefits from its subsidiary, Optum.

Matlock's health and insurance records and a mediation brief submitted in court by his mother show a young man struggling in his initial attempts to address his addiction:

In August 2020, Dougherty contacted her health plan and received approval to get Matlock into treatment.

Later that month, Matlock entered a residential facility in Riverside for the first time.

Convinced he could manage his addiction himself, he left after just 13 days. Five days later, he relapsed.

Later that fall, he returned to the same facility. This time he made it 30 days, followed by almost three weeks of outpatient treatment.

As soon as the program ended, he relapsed again.

He would later complain to his mother that the facility was treating him for heroin addiction, when he was actually addicted to fentanyl, according to a statement from Dougherty attached to the mediation brief.

In that statement, she described the weeks her son spent searching for a facility that specialized in fentanyl addiction and could also treat depression and other mental health issues.

Insurance records show Matlock called his health plan repeatedly, reporting a large collection of symptoms. One insurance company log, from January 2021, described a call in which Matlock complained of: "Loss of appetite, hot and cold flashes, restlessness, runny nose, cravings, insomnia, constipation, anxiety, goosebumps, joint pain, muscle pain, tremors, chills, depressed mood, irritability, mood swings, impulsivity, fatigue, heart palpitations, tension, difficulty concentrating, headaches, sensitivity to light, paranoid ideations expressing free floating fear of unknown and lack of directions. Sweats, worry and hypervigilant."

On Feb. 26, 2021, United Health approved his request to detox in Pacifica Recovery, a six-bed facility in Palm Desert.

The health plan's initial reviewer noted that Matlock had "spiraled out of control with substance ues (sic)" and that he was "fearful of killing self if he does not get help."

Upon his arrival, Pacifica recommended that Matlock stay at the facility for 90 days, according to the mediation brief. A doctor at the facility started him on a taper with buprenorphine to limit withdrawals. Matlock's symptoms responded immediately.

But three days after he was admitted to Pacifica, his counselor, Marc Stern, approached Matlock with bad news: the health plan had refused further coverage.

Stern, a longtime counselor who has been sober for more than 30 years, said he saw potential in Matlock, who struck him as bright, inquisitive and kind.

Matlock seemed to intuitively know when other clients were struggling, Stern remembered — he would stop by the counselor's office to alert him.

Despite the health plan's decision, the counselor knew this kid wasn't ready for the outside world.

"Fuck them," Stern recalls saying. "He's staying here."

Insurance appeals and denials

Ryan Matlock appealed that initial denial.

Most people don't even do that.

According to a 2023 study by KFF (formerly Kaiser Family Foundation) of people insured by Affordable Care Act plans, less than two-tenths of 1% of people who were denied treatment filed an appeal with their health plans.

In part, that's because people don't understand the appeals process or know their rights, said Kaye Pestaina, director of the KFF's program on patient and consumer protections. The requisite paperwork can be difficult to complete, she said, and often requires a health provider's assistance.

Facilities also have to be willing to invest significant time and resources to convince health plans to keep covering patients' stays. Shawna Morris, chief executive of Casa Pacifica, said her Central Coast-based organization hired a full-time licensed clinician whose entire job is to work with insurance companies to advocate for patients to stay longer.

"A whole industry has been built around regulating and denying care and that makes me nauseous," she said. "And then we build our own industry around fighting for and trying to get authorization for care."

The doctor who reviewed Matlock's case for Optum was Dr. Svetlana Libus, a psychiatrist who identified herself in the denial letter she sent Matlock as a behavioral medical director for the plan.

Dr. Libus did not respond to several emails and phone calls requesting an interview.

According to Matlock's insurance records, the mediation brief and her denial letter, Dr. Libus decided he did not meet the criteria to remain at Pacifica for a variety of reasons. Among them: He was no longer experiencing withdrawal, he was medically stable, he wasn't reporting unsafe thoughts, and he was participating in treatment and taking his medication as prescribed. She also noted that Matlock had already been in residential treatment, and had relapsed.

In her notes from the file, the doctor appears to have questioned his motives for seeking treatment again.

"I expressed concern that the (patient) comes to detox and relapses despite of all treatment attempts," Dr. Libus wrote, at one point misidentifying Matlock as a woman. "This could be indicative of pt using detox for reducing amount of substances she needed to get high . (Another reviewer) shared that same concern. I also express concerns that offering pt the same interventions all over again are becoming part of the enabling system."

She concluded that Matlock could "safely and effectively be treated" in an outpatient setting, according to the health records.

Dougherty said she begged the health plan to get on the phone with her son.

"Have you talked to him this time? Because it's different,'" she remembers imploring them. "'Have you talked to him about what his goals are? Have you seen the change? Have you talked to him?'"

"And they said, 'No, we don't need to.'"

If a patient's request for further treatment is denied, facilities have to make a tough decision – do they keep a patient on and continue to appeal, potentially absorbing the cost if the health plan won't pay?

In Matlock's case, his counselor, Stern, followed through on his promise: According to Stern's declaration in the family's lawsuit, Pacifica kept Matlock for two and a half more weeks while continuing to appeal to the health plan to reverse its decision. They charged only for food, Dougherty said.

During that time, Matlock seemed to his family and Stern to be making strides. For the first time in years, Dougherty noticed the light was back in her son's blue eyes.

He started talking to them about his future, outlining the steps to get recertified as an emergency medical technician. He planned to pursue his dream of becoming a wildland firefighter.

He joined Narcotics Anonymous and met every day with a sponsor, they said. He connected with three other young men at Pacifica who made a pact to stay sober together. Stern got them all matching buttons.

In one impassioned journal entry, Matlock wrote a goodbye letter to his addiction:

"You've almost taken my life from me twice. I'll be damned if I let that happen."

Can California better regulate mental health coverage?

Could California regulators have intervened to help Matlock?

Maybe if they had known about his case.

After his health plan denied his appeal, Matlock had the right to appeal yet again: this time to the state Department of Managed Health Care.

Both the Department of Managed Health Care and the Department of Insurance allow people to request independent medical reviews, in which outside experts review cases for the state and determine whether a health plan rightfully denied treatment.

Matlock might have had a decent chance at success. According to the Department of Managed Health Care annual reports, of 186 independent medical reviews of Optum decisions during the past decade, 60% were either overturned by the state or reversed by the health plan.

But Matlock's mother, Dougherty, said she and her son didn't know about this level of appeal. Most people don't.

Grant, of the California Association of Health Plans, also pointed to the fact that less than a tenth of a percent of full service health plan enrollees submit an appeal to the state.

But in her email, she interpreted the lack of appeals in a positive way:

"This is not to diminish the fact that each and every enrollee matters, but just to put into perspective that 99.99% of enrollees are getting the care they need," she said.

Hearing her explanation, Sen. Scott Wiener, the parity law's author and chair of the Senate Select Committee on Mental Health and Addiction, had a quick response: "I just don't buy that."

Advocates and some legislators have long expressed frustration that the state has not taken a more proactive role in holding health plans to account for refusing to pay for behavioral health care. Waiting for people in crisis to figure out how to navigate a complicated system is simply too passive, they say.

In California, that confusion is exacerbated by the fact that the Department of Managed Health Care and the Department of Insurance each regulates a different subset of health plans and insurers. Some aren't regulated by the state at all, but instead are regulated by the U.S. Department of Labor.

The relatively few people who do file for independent medical reviews with the state can find themselves waiting a long time: last year, it took the Department of Managed Health Care 35 days on average to complete reviews for mental health cases related to medical necessity.

"Aggressive monitoring and oversight by the regulators should really address this troubling trend," said Meiram Bendat, a Santa Barbara-based attorney and psychotherapist who helped author California's 2020 mental health coverage law. "It seems to me yet again another example of lack of regulatory oversight."

Lawmakers tried this year to legislate stricter state oversight.

State Sen. Dave Cortese, a Campbell Democrat, introduced Senate Bill 999, which would have required health plans to use mental health and addiction experts to review claims for treatment.

Sen. Wiener introduced Senate Bill 294, which would have required an automatic review when commercial health plans denied children and young people mental health treatment.

"The fact that we even have to consider that bill is an indictment of the system," he said.

Both bills died in the Senate Appropriations Committee, with advocates and lawmakers raising concerns that the Newsom administration had intentionally inflated cost estimates in order to kill them.

Sherry Daley, a longtime lobbyist with the California Consortium of Addiction Programs and Professionals, said her organization is now looking into modeling legislation after a New Jersey law that prevents health plans from reviewing whether a patient should be allowed to stay in substance use treatment for at least 28 days after their doctor has decided they belong there. Similar laws exist in New York and Pennsylvania, she said.

Several advocates and lawmakers also said they were concerned by the lack of publicly available data about how often health insurers deny authorization for mental health treatment, including the rates of denial by individual reviewers.

Watanabe, of the Department of Managed Health Care, told CalMatters the plans aren't required to submit that specific information to her department.

"We're always happy to accept information from anybody who wants to share something with us for us to look into," she said.

Remembering Ryan

The coroner's inspector who arrived at Ryan Matlock's bedroom on the morning of March 23, 2021 described the scene in cold detail:

Two clear plastic baggies with round light blue pills labeled M30 on the bed.

A Tilly's credit card with white powdered residue on the dresser.

A tattoo of a rose on Matlock's left abdomen.

A tag, number 01764, on his right big toe.

For Christine Dougherty, that day remains a nightmarish blur. She remembers the terror in her daughter's voice on the phone that morning, speaking words Dougherty could hear but couldn't make herself understand.

Until she and Haley moved this year, Dougherty left her son's clothes hanging in his closet, his 27 pairs of shoes — how he loved shoes! — laid out on the floor just as he had left them.

On the anniversary of Matlock's death, she and Haley got tattoos of hearts on their wrists with his ashes inked into them. On his birthday, they and many of his friends hit up his beloved In-N-Out to order his favorite meal: a Double-Double burger with Animal-Style fries and a blue Mountain Dew.

After Matlock died, Dougherty's attorney, Travis Corby, commissioned a review of his case from Dr. Mario Bartolome, a Roseville physician board certified in addiction medicine. Bartolome pushed back against many of the reasons Optum gave for denying Matlock coverage, including that Matlock had been in treatment in the past and relapsed.

"People who have been in treatment and failed that level of care need higher levels of service, not lower," he wrote.

OptumHealth Behavioral Solutions of California, Dr. Bartolome wrote, "inappropriately denied continuation of coverage" to Matlock, which "significantly contributed to his ultimate death by drug overdose soon after leaving treatment."

The year Ryan died, 317 people in San Bernardino County died of drug overdoses.

In California, that year, fentanyl alone claimed 5,961 lives. The next year, the toll climbed to 6,473. Last year, it hit 6,850.

Dougherty knows her son made the decision to buy the pills that killed him.

She also knows he wanted to live.

CalMatters data reporter Erica Yee contributed to this story.

Data methodology

In the absence of comprehensive public data, CalMatters sought data directly from companies who work with behavioral health treatment services. A version of that data was originally shown to our reporters by Joan Borsten, the former executive director of Summit Estate Recovery Center. Data from one billing company, which asked not to be named, provides a limited window into the appeals process.

The company provided internal records of appeals to a variety of health plans for higher level behavioral health care, with the patient and site of treatment anonymized. The data comprises more than 2,000 appeals from 2021 to 2024 for patients at treatment centers across the country, including in California. Each record includes a field for the name of the doctor working for the health plan who reviewed the appeal. However, many records are incomplete and doctor names show up inconsistently. In conversation with people who work with the data at the company paired with external research, CalMatters standardized the data and was able to group most appeal cases by the doctor who reviewed the case outcome. For the 40 identifiable doctors who show up the most frequently – each with at least 10 cases with complete information – the denial rates in the dataset range from 7% to 100%. Partial approvals, such as approving 3 out of 5 requested days of additional residential treatment, are counted as approvals not denials.