Visceral Belly Fat & How To Lose It
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Visceral Belly Fat & How To Lose It
We’ve talked before about how waist circumference is a much more useful indicator of metabolic health than BMI.
So, let’s say you’ve a bit more around the middle than you’d like, but it stubbornly stays there. What’s going on underneath what you can see, why is it going on, and how can you get it to change?
What is visceral fat?
First, let’s talk about subcutaneous fat. That’s the fat directly under your skin. Women usually have more than men, and that’s perfectly healthy (up to a point); it’s supposed to be that way. We (women) will tend to accumulate this mostly in places such as our breasts, hips, and butt, and work outwards from there. Men will tend to put it on more to the belly and face.
Side-note: if you’re undergoing (untreated) menopause, the changes in your hormone levels will tend to result in more subcutaneous fat to the belly and face too. That’s normal, and/but normal is not always good, and treatment options are great (with hormone replacement therapy, HRT, topping the list).
Visceral fat (also called visceral adipose tissue), on the other hand, is the fat of the viscera—the internal organs of the abdomen.
So, this is fat that goes under your abdominal muscles—you can’t squeeze this (directly).
So what can we do?
Famously “you can’t do spot reduction” (lose fat from a particular part of your body by focusing exercises on that area), but that’s about subcutaneous fat. There are things you can do that will reduce your visceral fat in particular.
Some of these advices you may think “that’s just good advice for losing fat in general” and it is, yes. But these are things that have the biggest impact on visceral fat.
Cut alcohol use
This is the biggie. By numerous mechanisms, some of which we’ve talked about before, alcohol causes weight gain in general yes, but especially for visceral fat.
Get better sleep
You might think that hitting the gym is most important, but this one ranks higher. Yes, you can trim visceral fat without leaving your bed (and even without getting athletic in bed, for that matter). Not convinced?
- Here’s a study of 101 people looking at sleep quality and abdominal adiposity
- Oh, and here’s a meta-analysis with 56,000 people (finding the same thing), in case that one study didn’t convince you.
So, the verdict is clear: you snooze, you lose (visceral fat)!
Tweak your diet
You don’t have to do a complete overhaul (unless you want to), but a few changes can make a big difference, especially:
- Getting more fiber (this is the biggie when it comes to diet)
- Eating less sugar (not really a surprise, but relevant to mention)
- Eat whole foods (skip the highly processed stuff)
If you’d like to learn more and enjoy videos, here’s an informative one to get you going!
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Most People Who Start GLP-1 RAs Quit Them Within A Year (Here’s Why)
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Specifically, 54% quit within one year, with that number rising to 72% within two years.
We first wrote about GLP-1 receptor agonists (i.e. semaglutide drugs like Ozempic and Wegovy) a couple of years ago when popularity was just beginning to take off:
However, as we had room only to touch briefly on the side effects and what happens when you stop taking it, you might also want to check out:
What happens when I stop taking a drug like Ozempic or Mounjaro?
…and:
Notwithstanding all this information, there’s a lot of science that has still yet to be done. If you’re a regular 10almonds reader, you’ll be familiar with our research review articles—this one was more of a non-research review, i.e. looking at the great absence of evidence in certain areas, and the many cases of research simply not asking the right questions, for example:
❝Of the four studies that actually looked at the macros (unlike most studies), they found that on average, protein intake decreased by 17.1%. Which is a big deal!
It’s an especially big deal, because while protein’s obviously important for everyone, it’s especially important for anyone trying to lose weight, because muscle mass is a major factor in metabolic base rate—which in turn is much important for fat loss/maintenance than exercise, when it comes to how many calories we burn by simply existing.
A reasonable hypothesis, therefore, is that one of the numerous reasons people who quit GLP-1 agonists immediately put fat back on, is because they probably lost muscle mass in amongst their weight loss, meaning that their metabolic base rate will have decreased, meaning that they end up more disposed to put on fat than before.❞
Read in full: Semaglutide’s Surprisingly Unexamined Effects ← there are a lot more (equally concerning) items discussed in this article
Why people quit GLP-1 RAs
There was a large (n=125,474) study of US adults. The average age was about 54 years, and about 65% were female.
From the total data pool (i.e. not narrowing it down by demographic), 54% stopped within a year, and 72% within two years.
The factors most associated with discontinuation were:
- age above 65 years
- not having type 2 diabetes
The main reasons given for discontinuation were:
- High costs: self-explanatory, but it’s worth noting that people who stopped for this reason were more likely to restart later.
- Adverse side effects: the most common ones were nausea, vomiting, diarrhea, constipation, stomach pain, and loss of appetite. Rarer, but more seriously, side effects included: pancreatitis (severe abdominal pain, nausea, vomiting), gallbladder issues (gallstones, cholecystitis), kidney problems, severe allergic reactions (rash, swelling, difficulty breathing), hypoglycemia, especially if taken with insulin or other diabetes medications, changes in vision (worsening diabetic retinopathy), and an increased heart rate.
- Disappointingly little weight loss: the researchers noted that GLP-1 RA results are “heterogenous”, meaning, they differ a lot. For those for whom it didn’t work, quitting was more likely, for obvious reasons. See also: 10 Mistakes To Sabotage Your Ozempic Progress
- Successful weight loss: while it is widely known that if one stops taking GLP-1 RAs, weight regain is the usual next thing to happen, there are a lot of people who go onto GLP-1 RAs with the rationale “I’ll just use this to lose the weight, and then I’ll keep the weight off with my diet and lifestyle”. Which sounds reasonable, but because of the specific mechanisms of actions of GLP-1 RAs, it simply doesn’t work that way (and, as we mentioned above, there are reasons that you may, after stopping taking GLP-1 RAs, be more disposed to put weight on than you were before you started). So, by the best of current science (which admittedly is not amazing when it comes to this topic), it does seem that taking GLP-1 RAs is a lifetime commitment.
You can read the study itself here:
Want to get similar results, without GLP-1 RAs?
Then check out:
5 Ways To Naturally Boost The “Ozempic Effect” ← this is about natural ways of doing similar hormone-hacking to what GLP-1 RAs do
and
Ozempic vs Five Natural Supplements ← this is about metabolism-tweaking supplements
and
Hack Your Hunger ← this is about appetite management
Take care!
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What Menopause Does To The Heart
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World Menopause Day: Menopause & Cardiovascular Disease Risk
Today, the 18th of October, is World Menopause Day.
The theme for this year is cardiovascular disease (CVD), and if your first reaction is to wonder what that has to do with the menopause, then this is the reason why it’s being featured. Much of the menopause and its effects are shrouded in mystery; not because of a lack of science (though sometimes a bit of that too), but rather, because it is popularly considered an unimportant, semi-taboo topic.
So, let’s be the change we want to see, and try to fix that!
What does CVD have to do with the menopause?
To quote Dr. Anjana Nair:
❝The metabolic and clinical factors secondary to menopause, such as dyslipidemia, insulin resistance, fat redistribution and systemic hypertension, contribute to the accelerated risk for cardiovascular aging and disease.
Atherosclerosis appears to be the end result of the interaction between cardiovascular risk factors and their accentuation during the perimenopausal period.
The increased cardiovascular risk in menopause stems from the exaggerated effects of changing physiology on the cardiovascular system.❞
Source: Cardiovascular Changes in Menopause
See also: Menopause-associated risk of cardiovascular disease
Can we do anything about it?
Yes, we can! Here be science:
- Menopause Transition and Cardiovascular Disease Risk: Implications for Timing of Early Prevention: A Scientific Statement From the American Heart Association
- Cardiovascular risk in menopausal women and our evolving understanding of menopausal hormone therapy: risks, benefits, and current guidelines for use
This (in few words: get your hormone levels checked, and consider HRT if appropriate) is consistent with the advice from gynecologist Dr. Jen Gunter, whom we featured back in August:
What You Should Have Been Told About The Menopause Beforehand
What about lifestyle changes?
We definitely can do some good things; here’s what the science has to say:
- Mediterranean diet: yes, evidence-based
- High soy consumption: mixed evidence, unclear. So, eat it if you want, don’t if you don’t.
- Supplements e.g. vitamins and minerals: yes, evidence-based.
- Supplements e.g. herbal preparations: many may help, but watch out for adverse interactions with meds. Check with your pharmacist or doctor.
- Supplements; specifically CBD: not enough evidence yet
- Exercise: yes, evidence-based—especially low-impact high-resistance training, for bone strength, as well as regular moderate-intensity exercise and/or High-Intensity Interval Training, to guard against CVD.
For a full low-down on all of these:
Revealing the evidence-based lifestyle solutions to managing your menopause symptoms
Want to know more?
You can get the International Menopause Society’s free downloadable booklet here:
Menopause & Cardiovascular Disease: What Women Need To Know
You may also like our previous main feature:
What Does “Balance Your Hormones” Even Mean?
Take care!
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The Good Life – by Robert Waldinger, MD, and Marc Schulz, PhD
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For any who have thought “there must be some middle-ground between entirely subjective self-help books advising how to feel better, and sifting through clinical data on what actually affects people’s moods“, this book is exactly that middle-ground!
Drs. Waldinger and Schultz went through the 80-year-long Harvard Study of Adult Development with a fine-toothed comb, and this book details—more readably—what they found.
There are frequent references to data from the study. Not just numbers, though, people’s answers to questions, too. And how different factors about people’s lives affected their answers to the same questions.
We hear from all ages, from young adults to octagenarians, and learn how attitudes (including: of the same people) change over time. Not because people are fickle, but because people grow… or become disillusioned. Or sometimes, both.
We learn about the importance of money… And where that importance ends.
We learn importance of relationships of various kinds, and this is certainly a recurring theme throughout the study—and thus, throughout the book.
The book doesn’t just present data, though, it also presents actionable insights along the way.
Bottom line: the combined wisdom and life-experiences of a lot of people provide a very “big picture” view of life, and what makes us happy, really. We highly recommend it!
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How to Stay Sane – by Philippa Perry
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First, what this book is not: a guide of “how to stay sane” in the popular use of the word “sane”, meaning free from serious mental illness of all and any kinds in general, and especially free from psychotic delusions. Alas, this book will not help with those.
What, then, is it? A guide of “how to stay sane” in the more casual sense of resiliently and adaptively managing stress, anxiety, and suchlike. The “light end” of mental health struggles, that nonetheless may not always feel light when dealing with them.
The author, a psychotherapist, draws from her professional experience and training to lay out psychological tools for our use, as well as giving the reader a broader understanding of the most common ills that may ail us.
The writing style is relaxed and personable; it’s not at all like reading a textbook.
The psychotherapeutic style is not tied to one model, and rather hops from one to another, per what is most likely to help for a given thing. This is, in this reviewer’s opinion at least, far better than the (all-too common) attempt made by a lot of writers to try to present their personal favorite model as the cure for all ills, instead of embracing the whole toolbox as this one does.
Bottom line: if your mental health is anywhere between “mostly good” and “a little frayed around the edges but hanging on by at least a few threads”, then this book likely can help you gain/maintain the surer foundation you’re surely seeking.
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8 Critical Signs Of Blood Clots That You Shouldn’t Ignore
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Blood clots can form as part of deep vein thrombosis or for other reasons; wherever they form (unless they are just doing their job healing a wound) they can cause problems. But how to know what’s going on inside our body?
Telltale signs
Our usual medical/legal disclaimer applies here, and we are not doctors, let alone your doctors, and even if we were we couldn’t diagnose from afar… But for educational purposes, here are the eight signs from the video:
- Swelling: especially if only on one leg (assuming you have no injury to account for it), which may feel tight and uncomfortable
- Warmness: does the area warmer to the touch? This may be because of the body’s inflammatory response trying to deal with a blood clot
- Tenderness: again, caused by the inflammation in response to the clot
- Discolored skin: it could be reddish, or bruise-like. This could be patchy or spread over a larger area, because of a clot blocking the flow of blood
- Shortness of breath: if a clot makes it to the lungs, it can cause extra problems there (pulmonary embolism), and shortness of breath is the first sign of this
- Coughing up blood: less common than the above but a much more serious sign; get thee to a hospital
- Chest pain: a sharp or stabbing pain, in particular. The pain may worsen with deep breaths or coughing. Again, seek medical attention.
For more on recognizing these signs (including helpful visuals), and more on what to do about them and how to avoid them in the first place, enjoy:
Click Here If The Embedded Video Doesn’t Load Automatically!
Further reading
You might like to read:
Dietary Changes for Artery Health
Take care!
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Her Mental Health Treatment Was Helping. That’s Why Insurance Cut Off Her Coverage.
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Reporting Highlights
- Progress Denials: Insurers use a patient’s improvement to justify denying mental health coverage.
- Providers Disagree: Therapists argue with insurers and the doctors they employ to continue covering treatment for their patients.
- Patient Harm: Some patients backslid when insurers cut off coverage for treatment at key moments.
These highlights were written by the reporters and editors who worked on this story.
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.
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.”
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, of which private insurance paid about a third. One 2024 study 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, 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 designed 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.
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 or for “solely” basing their decisions on them.
Wit v. United Behavioral Health, 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 that 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 have 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 that 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 “reviewed 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.
In another case, 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.
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.”
Kirsten Berg contributed research.
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