by Duaa Eldeib, photography by Sarah Blesener for ProPublica

This story contains graphic descriptions of suicide attempts.

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The email took Dr. Neal Goldenberg by surprise in a way that few things still do.

As a psychiatrist, he had grown accustomed to seeing patients in their darkest moments. As someone who reviewed insurance denials, he was also well-versed in the arguments that hospitals make to try to overturn an insurer’s decision not to pay for treatment.

But as soon as he opened the review last October, he knew something was different. It was personal and forceful and meticulous — and it would lead him to do something he had never done before.

“Based on the indisputable medical facts, we are unsure why anyone would assert that any part of the insured’s inpatient behavioral health treatment was ‘not medically necessary,’” the appeal letter argued.

The battle playing out on the pages before him began in March of 2024. Highmark Blue Cross Blue Shield had refused to pay for a North Carolina man’s monthlong treatment at a psychiatric hospital. The man had been suffering escalating mental health issues, culminating in back-to-back suicide attempts. But using a designation insurers commonly employ when denying coverage, doctors working for Highmark determined the care was not “medically necessary.”

Insurance companies deny hundreds of millions of claims a year, and only a tiny percentage of people appeal them. Even fewer take the process to the very end, appealing to a third-party, or external, reviewer like Goldenberg. A recent report found that, on average, less than 1 out of every 10,000 people eligible for an external review actually requested one.

Goldenberg, who is based in Cleveland, had initially picked up the extra job a few years ago to help pay down the massive student debt he and his wife, a family doctor, had accumulated during medical school.

In that role, he has the power to overrule an insurer’s decision to deny a patient coverage and force the company to pay for treatment. Few things anger him as much as patients being denied the care they needed, which compelled him to continue doing the reviews even after the student loans were paid off.

Attached to the appeal letter were nearly 200 pages of records organized by headings and numbers. There was even a glossary of diagnosis codes that are used for billing.

Goldenberg’s first thought was that a lawyer had put together the appeal. But the name on the bottom of the letter didn’t belong to a law firm.

He spent the next hour and a half reading the file: records from eight separate medical providers; research on suicidal ideation; letters from two psychiatrists supporting the appeal, including one that described the patient’s depression and stress as causing “psychological suffering and functional impact.”

Then he did something he hadn’t done in the six years he’s been reviewing cases. He called the name at the bottom of the letter: Teressa Sutton-Schulman.

The line rang several times before going to voicemail.

“Hello. My name is Neal Goldenberg. I am reviewing an insurance claim for your husband,” he began.

Sutton-Schulman’s husband, who ProPublica is identifying by his middle initial “L,” had always been anxious and more than a little obsessive. As an adult, financial matters, especially, threw him into a panic and eventually sent him to therapy.

By January of last year, after deciding that the therapy wasn’t working, he made an appointment with his primary care doctor, who prescribed him an antidepressant and antianxiety medication. After a few days, L called the doctor to say he felt worse. A panic attack landed him in the emergency room about a week later.

Right before Valentine’s Day, he met with a psychiatrist.

The way his mind had begun to shuffle through worst-case scenarios was something Sutton-Schulman hadn’t witnessed before.

They met at Georgia Tech. L had noticed her at a party. When he walked up to her, she told him she was waiting for someone.

“I could be someone,” he responded without missing a beat.

She was drawn to his humor and charm. As an introvert, Sutton-Schulman marveled at the way his presence filled a room, floating between people and the things they talked about with ease. He considered her his rock, his best friend, the person he loved most in this world.

They shared a mutual admiration for each other’s intellect and drive. He skewed nerdy, playing Dungeons & Dragons in his downtime. Not that he had much. As a rising star in the world of software engineering, work consumed him. He craved success the same way he pushed the boundaries of technology — relentlessly.

They decided not to have kids; they had each other and their work. In the early 2000s, they built a software consulting company together. Although Sutton-Schulman trained as a chemist, she went back to school to become a paralegal and the company’s in-house legal expert.

More than 20 years into their marriage, they still held hands like it was their first date. When they entered their 50s and faced the prospect of growing old in their three-story house, they decided to buy a ranch home in the same small North Carolina town outside of Raleigh that they had lived in for more than two decades.

That decision would forever alter their lives.

The pandemic’s housing market, with its skyrocketing prices and houses that sold before they even went on the market, exacerbated his stress. The couple put offers on half a dozen houses. They lost $25,000 in earnest money after backing out of the only two offers that were accepted. The hit hurt, but thanks to L’s job, they had more than enough in the bank.

Finally, in the summer of 2023, they found their house, though it needed some work. They decided to rent out their old house, but that, too, required some fixing up before they could put it on the market. L was determined to get a renter in quickly, and they poured money into both houses simultaneously.

L’s anxiety grew with every expense. They argued about money, about his insistence on undertaking everything at once, about his unwillingness to get treatment, about their five cats. She begged him to get help. He assured her he had it all under control.

After two months, they moved into the new house.

L grew more irrational each day. All he could do was fixate on the finances. On top of it all, they weren’t sleeping. To help with the cats’ transition to the new house, Sutton-Schulman had talked to L about getting them an enclosed space on their patio. But L, who was overseeing the remodeling, didn’t prioritize it. The cats kept them up each night with their incessant whining and scratching at their doors.

She knew that all of his concerns were symptoms of a larger problem, but neglecting to take care of the cats was the final straw. As hard as it was for her to leave him, she felt like she had no other choice. Two weeks after moving in, she packed her bags and her SUV and moved back into their old house.

It took her leaving for him to see a therapist and agree to couple’s counseling.

Buying the house, he told his wife, was a mistake.

If you or someone you know needs help, here are a few resources:

• Call the National Suicide Prevention Lifeline: 988

• Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

“I started catastrophizing every day,” L said at his appointment with his psychiatrist right before Valentine’s Day, medical records show.

L told him that he regularly woke up at 2:30 a.m. in the throes of a nightmare. His heart raced. His legs felt weak. He contemplated ending his life.

The psychiatrist tried to determine how serious his suicidal thoughts were. L admitted he felt anxious and hopeless, but he said he was afraid to die.

“I’m a fucking coward and I can’t do it,” L told the psychiatrist, according to his medical records. “I don’t know how to kill myself.”

Two days later, he swallowed a bottle of sleeping pills and chased them down with bourbon. He slid into the driver’s seat of his Mercedes parked in the garage, turned on the ignition and closed his eyes.

Goldenberg’s path to medicine began at a young age. He excelled in science in school. He grew up with a dad who was a dentist and a belief that doctors could heal.

But 2003, his first year of medical school, was difficult. He........

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