Patrick Rucker, Maya Miller and David Armstrong, ProPublica

Trump's DOJ drops 1,000+ terrorism cases while promising to 'make America safe'

In the first days after Pam Bondi was appointed attorney general last year, the Department of Justice began shutting down pending criminal cases at a record pace.

The cases included an investigation into a Virginia nursing home with a recent record of patient abuse; probes of fraud involving several New Jersey labor unions, including one opened after a top official of a national union was accused of embezzlement; and an investigation into a cryptocurrency company suspected of cheating investors.

In total, the DOJ quietly closed more than 23,000 criminal cases in the first six months of President Donald Trump’s administration, abandoning hundreds of investigations into terrorism, white-collar crime, drugs and other offenses as it shifted resources to pursue immigration cases, according to an analysis by ProPublica.

The bulk of these cases, which were closed without prosecution and known as declinations, had been referred to the DOJ by law enforcement agencies under prior administrations that believed a federal crime may have been committed. The DOJ routinely declines to prosecute cases for any number of reasons, including insufficient evidence or because a case is not a priority for enforcement.

But the number of declinations under Bondi marks a striking departure not only from the Biden administration but also the first Trump term, according to the ProPublica analysis, which examined two decades of DOJ data, including the first six months of Trump’s second term. ProPublica determined the increase is not the result of inheriting a larger caseload or more referrals from law enforcement.

In February 2025 alone, which included the first weeks of Bondi’s tenure, nearly 11,000 cases were declined, the most in a month since at least 2004. The previous high was just over 6,500 cases in September 2019, during Trump’s first administration.

Some of the cases shut down were the result of yearslong investigations by federal agencies such as the FBI and the Drug Enforcement Administration. For complex cases, the DOJ can take years before deciding whether to bring charges.

The shift comes as the DOJ has undergone an extraordinary overhaul under the Trump administration, with entire units shuttered, directives to abandon pursuit of certain crimes and thousands of lawyers quitting or, in some cases, being forced out of the agency.

In doing so, the DOJ is retreating from its mission to impartially uphold the rule of law, keep the country safe and protect civil rights, according to interviews with a dozen prosecutors and an open letter from nearly 300 DOJ employees who have left the department under Trump. The Trump DOJ, the employees wrote, is “taking a sledgehammer” to long-standing work to “protect communities and the rule of law.”

The change in priorities was outlined in a series of memos sent to attorneys early last year. Trump’s DOJ has said it is “turning a new page on white-collar and corporate enforcement” and emphasizing the pursuit of drug cartels, illegal immigrants and institutions that promote “divisive DEI policies.” Trump, in an address last March at the department, said the changes were necessary after a “surrender to violent criminals” during the past administration and would result in a restoration of “fair, equal and impartial justice under the constitutional rule of law.”

The department prosecuted 32,000 new immigration cases in the first six months of the administration, which was nearly triple the number under the Biden administration and a 15% increase from the first Trump term. It has pursued fewer prosecutions of nearly every other type of crime — from drug offenses to corruption — than new administrations in their first six months dating back to 2009.

The DOJ has also closed hundreds of cases involving alleged crimes that the administration has publicly emphasized as enforcement priorities. Even as the Trump administration unleashed Elon Musk’s Department of Government Efficiency operatives to root out waste, fraud and abuse in the federal government, the DOJ declined over 900 cases of federal program or procurement fraud. About three times as many cases of major fraud against the U.S. were declined under Trump compared with the average of similar time periods under prior administrations. And while the Trump administration has promised to “make America safe again,” its DOJ has declined more than 1,000 terrorism cases, also more than prior administrations.

Federal prosecutor Joseph Gerbasi had spent years in the department’s Narcotic and Dangerous Drug Section helping build cases against major suppliers of fentanyl ingredients in India and China. After Bondi came in, he was left bewildered when his team was ordered to abandon its work.

“All of the building blocks of what would become successful prosecutions were pulled out,” said Gerbasi, who retired as the section’s acting deputy chief for policy in March 2025 after 28 years with the department.

The move had an “overwhelming deflating effect on morale,” he said.

Barbara McQuade, who worked as a federal prosecutor in Michigan for two decades until 2017 during Republican and Democratic administrations, said it was not unusual for new administrations to come to office with a few “pet priorities” — such as a focus on violent crime or drug trafficking. But she said those changes usually involved modest adjustments in policy and that most of the decisions on what crimes to focus on were typically made at the local level by the district U.S. attorney in coordination with the FBI or other agencies.

“We would revise those about every five years, not having anything to do with any administration, just because it made sense,” she said.

A DOJ spokesperson, in an emailed response to questions about the spike in declinations, said that in “an effort to clean, remediate, and validate data in U.S. Attorneys’ case management system,” the department reviewed all pending criminal matters opened prior to the 2023 fiscal year, which included updating the status of closed cases. “This Department of Justice remains committed to investigating and prosecuting all types of crime to keep the American people safe, and the number of declinations is a direct result of our efforts to run the agency in a more efficient manner.”

The agency did not respond to questions about the types of cases declined.

The spike of declined cases began in February 2025 when the department ordered prosecutors to review every open case launched prior to October 2022 and determine whether to close it. Such a review would typically take months, according to one attorney tasked with reviewing cases. A memo, which was described to ProPublica reporters, ordered the review to be completed within 10 days.

Former DOJ prosecutors told ProPublica that they typically reviewed caseloads every six months with supervisors and that closing out languishing cases wouldn’t ordinarily be cause for concern. They said the February directive, however, was unusual. None could recall a similar order.

The directive came as higher-ups in the department had begun making frequent demands for data about specific types of cases and charging decisions, such as the outcome of fentanyl cases, according to former prosecutor Michael Gordon. Gordon, who helped prosecute Jan. 6 cases before moving to white-collar crime prosecutions, said the “fire drills” from officials in Washington became so regular that he grew used to the forlorn look on his supervisor’s face when he showed up at Gordon’s door, apologetically delivering yet another frantic request.

“It was either ‘give us stats we can use to make ourselves look good’ or ‘give us the stats to show how bad things are in this area,’” Gordon said. “It was never productive fact-finding.”

Though Gordon didn’t see the memo, he remembered getting the request to review all cases that had been open for more than two years and report back on their status, entering into a master spreadsheet basic information about any that he wanted to keep pursuing.

“The office was pushing us to close everything by a certain date so that when they had to report up to D.C. they had a low number of open cases,” he said. “You really had to go to bat to keep open a case that was more than two years old.”

Gordon said he was fired by the DOJ last June. He has filed a lawsuit alleging his termination was politically motivated. The department did not respond to questions about Gordon’s comments or his lawsuit. The government filed a motion to dismiss the case late last year, arguing that the federal court did not have jurisdiction over the matter. The court has not yet ruled on that motion, and the case is still pending.

Investigations into individuals or corporations declined for prosecution are generally not reported to courts and usually only disclosed in summary form by the DOJ in annual reports. To conduct its analysis, ProPublica obtained declination data from the DOJ and the Transactional Records Access Clearinghouse, a center that obtains data through Freedom of Information Act requests.

Here are some of the areas most impacted by the spike in declinations.

Drugs

As president, Trump has spoken frequently about the “scourge” of drugs coming into the country. At the same time, the Justice Department has declined to prosecute nearly 5,000 cases of federal drug law violations, including trafficking and money laundering. The number of declinations were 45% higher than the average of the prior three new administrations.

Gerbasi, the counternarcotics prosecutor, declined to comment on specific cases that might have been declined in his office. But, he said, once Bondi was appointed, the priority in the office became building cases against Tren de Aragua, a Venezuelan group that the Trump administration has labeled a foreign terrorist organization.

“Tren de Aragua was not anywhere close to the scale or impact of the cartels we were focused on,” Gerbasi said. “But we were told to generate those cases.”

He said his office had to scramble to fly people to investigate local gangs in small towns that were reportedly affiliated with Tren de Aragua. “They never would have merited a full-scale federal investigation,” he said.

“It told me that decisions were going to be based on political appearances and not based on the merits of where investigative resources should be placed.”

The DOJ declined to comment on Gerbasi’s remarks.

National Security

Under Bondi, the DOJ declined more than 1,300 cases involving terrorism and national security, nearly twice what was typical at the start of the most recent new administrations. While domestic terrorism was the hardest-hit program, just over 300 cases involving charges of providing material support to foreign terrorist organizations were also dropped.

The DOJ program handling matters relating to national internal security — which considers cases of alleged spy activity and the security of classified information — saw over 200 declinations, which is four times as many as typical in the first six months of a new administration. Some of the cases related to serving as an unregistered foreign agent, a charge Bondi ordered prosecutors to stop pursuing unless they involved “conduct similar to more traditional espionage by foreign government actors.”

Jimmy Gurulé, a former federal prosecutor and George W. Bush appointee to the U.S. Treasury Department who investigated the financing of terrorism, said the decline in terrorism cases was troubling.

“The Trump DOJ has been used as a political weapon,” he said. “It’s a question of prioritizing resources. Are they going to be used for national security threats or to prosecute his political enemies and critics?” The DOJ did not respond to a request for comment on Gurulé’s remarks.

Labor

The DOJ shut down over 60 union corruption and labor racketeering cases, 2.5 times the number in Trump’s first term. Nearly half of the cases turned down for those offenses were out of the New Jersey U.S. attorney’s office, which in the past has aggressively pursued alleged union corruption. All were noted as declined for insufficient evidence.

Most of those cases had been opened by Grady O’Malley, an assistant U.S. attorney who oversaw several prosecutions of union corruption while working in the New Jersey office over four decades. He retired in 2023 and was disturbed to learn from former colleagues that the office was shutting down the open union probes.

A Trump supporter, O’Malley said that while he doesn’t blame the president, he worries the decision to drop so many cases could embolden unions that he and his colleagues spent years working to hold accountable. “No one is assigned to do labor union cases, and the unions have every reason to believe no one is looking.”

The New Jersey U.S. attorney’s office said it had no comment on the declination of labor cases.

White-Collar Crime

The Trump administration has pledged to root out “rampant” fraud in federal benefit programs like food stamps and welfare. The controversial surging of federal agents to Minnesota in January began as a stated crackdown on noncitizens allegedly ripping off nutrition and child care programs.

The DOJ, however, shut down more than 900 cases of federal program or procurement fraud in the first six months of the administration, including one targeting a mortgage lender accused by several state regulators of defrauding the Federal Housing Administration. The case was dropped due to “prioritization of federal resources and interests.” The U.S. attorney’s office for the Northern District of Alabama, which declined the case, did not reply to a request for comment. The number of fraud cases closed was about double that in the same time period of the Biden and first Trump administrations.

The agency also closed over 100 health care fraud cases as a result of “prioritization of resources and interests” even though the Trump administration has said it is making this area of enforcement a priority.

Among other cases the DOJ determined weren’t a priority: the probe into the Virginia nursing home accused of abuse, as well as investigations in Tennessee into fraud at a national hospital chain and one of the largest Medicaid managed care companies.

The Western District of Virginia U.S. attorney’s office, through a spokesperson, declined to comment on the nursing home case. A spokesperson for the U.S. attorney in the Middle District of Tennessee said the office does not comment on investigations that do not result in public charges.

The DOJ’s Antitrust Division, which focuses on preventing big businesses from creating harmful monopolies, also declined an unusually high number of cases in Trump’s second term. More than 40 cases were dropped within the first six months of Bondi’s tenure. That’s more than double the number declined in the same time period by the prior three new administrations.

Despite the declinations, the department said it charged slightly more people with fraud in 2025 compared with the final year of the Biden administration, and those cases alleged larger financial losses.

Promises Kept

The DOJ under Bondi has also rapidly pursued many of the priorities laid out in Trump’s early executive orders and her own “first day” directives to staff.

Trump in February 2025 issued an executive order pausing new investigations under the Foreign Corrupt Practices Act, which prohibits citizens and companies from bribing foreign entities to advance their business interests. The order asked the attorney general to review and “take appropriate action” on any existing probes to “preserve Presidential foreign policy prerogatives.”

In the first six months, Bondi’s DOJ shut down 25 such cases, which is more than the combined number dropped by the prior three new administrations over the same time period. One of the cases declined for prosecution involved a major car manufacturer, which had reported possible anti-bribery violations to federal investigators involving a foreign subsidiary. The DOJ declined the case for prosecution last June, citing the “prioritization of federal resources and interests.”

On her first day, Bondi ordered a review of criminal prosecutions under the Freedom of Access to Clinic Entrances, or FACE Act, which prohibits people from illegally blocking access to abortion clinics and places of worship. The department dropped as many cases under the act in its first six months as the past three new administrations combined, over the same time frame. Bondi’s order focused on “non-violent protest activity,” although at least one of the closed cases was being investigated as a violent crime. The DOJ has since charged protesters against Immigration and Customs Enforcement and journalists in Minneapolis under the FACE Act. The defendants in the case have pleaded not guilty.

The agency closed three times the number of cases alleging environmental crimes as the Biden administration did and one-and-a-half times as many as compared with Trump’s first term. The declinations came as the DOJ reassigned and cut prosecutors working on environmental cases. One-fifth of all of the dropped environmental protection cases were shut down for “prioritization of federal resources and interests.”

How Cigna saves millions by having its doctors reject claims without reading them

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When a stubborn pain in Nick van Terheyden’s bones would not subside, his doctor had a hunch what was wrong.

Without enough vitamin D in the blood, the body will pull that vital nutrient from the bones. Left untreated, a vitamin D deficiency can lead to osteoporosis.

A blood test in the fall of 2021 confirmed the doctor’s diagnosis, and van Terheyden expected his company’s insurance plan, managed by Cigna, to cover the cost of the bloodwork. Instead, Cigna sent van Terheyden a letter explaining that it would not pay for the $350 test because it was not “medically necessary.”

The letter was signed by one of Cigna’s medical directors, a doctor employed by the company to review insurance claims.

Something about the denial letter did not sit well with van Terheyden, a 58-year-old Maryland resident. “This was a clinical decision being second-guessed by someone with no knowledge of me,” said van Terheyden, a physician himself and a specialist who had worked in emergency care in the United Kingdom.

The vague wording made van Terheyden suspect that Dr. Cheryl Dopke, the medical director who signed it, had not taken much care with his case.

Van Terheyden was right to be suspicious. His claim was just one of roughly 60,000 that Dopke denied in a single month last year, according to internal Cigna records reviewed by ProPublica and The Capitol Forum.

The rejection of van Terheyden’s claim was typical for Cigna, one of the country’s largest insurers. The company has built a system that allows its doctors to instantly reject a claim on medical grounds without opening the patient file, leaving people with unexpected bills, according to corporate documents and interviews with former Cigna officials. Over a period of two months last year, Cigna doctors denied over 300,000 requests for payments using this method, spending an average of 1.2 seconds on each case, the documents show. The company has reported it covers or administers health care plans for 18 million people.

Before health insurers reject claims for medical reasons, company doctors must review them, according to insurance laws and regulations in many states. Medical directors are expected to examine patient records, review coverage policies and use their expertise to decide whether to approve or deny claims, regulators said. This process helps avoid unfair denials.

But the Cigna review system that blocked van Terheyden’s claim bypasses those steps. Medical directors do not see any patient records or put their medical judgment to use, said former company employees familiar with the system. Instead, a computer does the work. A Cigna algorithm flags mismatches between diagnoses and what the company considers acceptable tests and procedures for those ailments. Company doctors then sign off on the denials in batches, according to interviews with former employees who spoke on condition of anonymity.

“We literally click and submit,” one former Cigna doctor said. “It takes all of 10 seconds to do 50 at a time.”

Not all claims are processed through this review system. For those that are, it is unclear how many are approved and how many are funneled to doctors for automatic denial.

Insurance experts questioned Cigna’s review system.

Patients expect insurers to treat them fairly and meaningfully review each claim, said Dave Jones, California’s former insurance commissioner. Under California regulations, insurers must consider patient claims using a “thorough, fair and objective investigation.”

“It’s hard to imagine that spending only seconds to review medical records complies with the California law,” said Jones. “At a minimum, I believe it warrants an investigation.”

Within Cigna, some executives questioned whether rendering such speedy denials satisfied the law, according to one former executive who spoke on condition of anonymity because he still works with insurers.

“We thought it might fall into a legal gray zone,” said the former Cigna official, who helped conceive the program. “We sent the idea to legal, and they sent it back saying it was OK.”

Cigna adopted its review system more than a decade ago, but insurance executives say similar systems have existed in various forms throughout the industry.

In a written response, Cigna said the reporting by ProPublica and The Capitol Forum was “biased and incomplete.”

Cigna said its review system was created to “accelerate payment of claims for certain routine screenings,” Cigna wrote. “This allows us to automatically approve claims when they are submitted with correct diagnosis codes.”

When asked if its review process, known as PXDX, lets Cigna doctors reject claims without examining them, the company said that description was “incorrect.” It repeatedly declined to answer further questions or provide additional details. (ProPublica employees’ health insurance is provided by Cigna.)

Former Cigna doctors confirmed that the review system was used to quickly reject claims. An internal corporate spreadsheet, viewed by the news organizations, lists names of Cigna’s medical directors and the number of cases each handled in a column headlined “PxDx.” The former doctors said the figures represent total denials. Cigna did not respond to detailed questions about the numbers.

Cigna's explanation that its review system was designed to approve claims didn’t make sense to one former company executive. “They were paying all these claims before. Then they weren’t,” said Ron Howrigon, who now runs a company that helps private doctors in disputes with insurance companies. “You’re talking about a system built to deny claims.”

Cigna emphasized that its system does not prevent a patient from receiving care — it only decides when the insurer won’t pay. “Reviews occur after the service has been provided to the patient and does not result in any denials of care,” the statement said.

"Our company is committed to improving health outcomes, driving value for our clients and customers, and supporting our team of highly-skilled Medical Directors,” the company said.

PXDX

Cigna’s review system was developed more than a decade ago by a former pediatrician.

After leaving his practice, Dr. Alan Muney spent the next several decades advising insurers and private equity firms on how to wring savings out of health plans.

In 2010, Muney was managing health insurance for companies owned by Blackstone, the private equity firm, when Cigna tapped him to help spot savings in its operation, he said.

Insurers have wide authority to reject claims for care, but processing those denials can cost a few hundred dollars each, former executives said. Typically, claims are entered into the insurance system, screened by a nurse and reviewed by a medical director.

For lower-dollar claims, it was cheaper for Cigna to simply pay the bill, Muney said.

“They don’t want to spend money to review a whole bunch of stuff that costs more to review than it does to just pay for it,” Muney said.

Muney and his team had solved the problem once before. At UnitedHealthcare, where Muney was an executive, he said his group built a similar system to let its doctors quickly deny claims in bulk.

In response to questions, UnitedHealthcare said it uses technology that allows it to make “fast, efficient and streamlined coverage decisions based on members benefit plans and clinical criteria in compliance with state and federal laws.” The company did not directly address whether it uses a system similar to Cigna.

At Cigna, Muney and his team created a list of tests and procedures approved for use with certain illnesses. The system would automatically turn down payment for a treatment that didn’t match one of the conditions on the list. Denials were then sent to medical directors, who would reject these claims with no review of the patient file.

Cigna eventually designated the list “PXDX” — corporate shorthand for procedure-to-diagnosis. The list saved money in two ways. It allowed Cigna to begin turning down claims that it had once paid. And it made it cheaper to turn down claims, because the company’s doctors never had to open a file or conduct any in-depth review. They simply denied the claims in bulk with an electronic signature.

“The PXDX stuff is not reviewed by a doc or nurse or anything like that,” Muney said.

The review system was designed to prevent claims for care that Cigna considered unneeded or even harmful to the patient, Muney said. The policy simply allowed Cigna to cheaply identify claims that it had a right to deny.

Muney said that it would be an “administrative hassle” to require company doctors to manually review each claim rejection. And it would mean hiring many more medical directors.

“That adds administrative expense to medicine,” he said. “It’s not efficient.”

But two former Cigna doctors, who did not want to be identified by name for fear of breaking confidentiality agreements with Cigna, said the system was unfair to patients. They said the claims automatically routed for denial lacked such basic information as race and gender.

“It was very frustrating,” one doctor said.

Some state regulators questioned Cigna’s PXDX system.

In Maryland, where van Terheyden lives, state insurance officials said the PXDX system as described by a reporter raises “some red flags.”

The state’s law regulating group health plans purchased by employers requires that insurance company doctors be objective and flexible when they sit down to evaluate each case.

If Cigna medical directors are “truly rubber-stamping the output of the matching software without any additional review, it would be difficult for the medical director to comply with these requirements,” the Maryland Insurance Administration wrote in response to questions.

Medicare and Medicaid have a system that automatically prevents improper payment of claims that are wrongly coded. It does not reject payment on medical grounds.

Within the world of private insurance, Muney is certain that the PXDX formula has boosted the corporate bottom line. “It has undoubtedly saved billions of dollars,” he said.

Insurers benefit from the savings, but everyone stands to gain when health care costs are lowered and unneeded care is denied, he said.

Speedy reviews

Cigna carefully tracks how many patient claims its medical directors handle each month. Twelve times a year, medical directors receive a scorecard in the form of a spreadsheet that shows just how fast they have cleared PXDX cases.

Dopke, the doctor who turned down van Terheyden, rejected 121,000 claims in the first two months of 2022, according to the scorecard.

Dr. Richard Capek, another Cigna medical director, handled more than 80,000 instant denials in the same time span, the spreadsheet showed.

Dr. Paul Rossi has been a medical director at Cigna for over 30 years. Early last year, the physician denied more than 63,000 PXDX claims in two months.

Rossi, Dopke and Capek did not respond to attempts to contact them.

Howrigon, the former Cigna executive, said that although he was not involved in developing PXDX, he can understand the economics behind it.

“Put yourself in the shoes of the insurer,” Howrigon said. “Why not just deny them all and see which ones come back on appeal? From a cost perspective, it makes sense.”

Cigna knows that many patients will pay such bills rather than deal with the hassle of appealing a rejection, according to Howrigon and other former employees of the company. The PXDX list is focused on tests and treatments that typically cost a few hundred dollars each, said former Cigna employees.

“Insurers are very good at knowing when they can deny a claim and patients will grumble but still write a check,” Howrigon said.

Muney and other former Cigna executives emphasized that the PXDX system does leave room for the patient and their doctor to appeal a medical director’s decision to deny a claim.

But Cigna does not expect many appeals. In one corporate document, Cigna estimated that only 5% of people would appeal a denial resulting from a PXDX review.

'A negative customer experience'

In 2014, Cigna considered adding a new procedure to the PXDX list to be flagged for automatic denials.

Autonomic nervous system testing can help tell if an ailing patient is suffering from nerve damage caused by diabetes or a variety of autoimmune diseases. It’s not a very involved procedure — taking about an hour — and it costs a few hundred dollars per test.

The test is versatile and noninvasive, requiring no needles. The patient goes through a handful of checks of heart rate, sweat response, equilibrium and other basic body functions.

At the time, Cigna was paying for every claim for the nerve test without bothering to look at the patient file, according to a corporate presentation. Cigna officials were weighing the cost and benefits of adding the procedure to the list. “What is happening now?” the presentation asked. “Pay for all conditions without review.”

By adding the nerve test to the PXDX list, Cigna officials estimated, the insurer would turn down more than 17,800 claims a year that it had once covered. It would pay for the test for certain conditions, but deny payment for others.

These denials would “create a negative customer experience” and a “potential for increased out of pocket costs," the company presentation acknowledged.

But they would save roughly $2.4 million a year in medical costs, the presentation said.

Cigna added the test to the list.

'It’s not good medicine'

By the time van Terheyden received his first denial notice from Cigna early last year, he had some answers about his diagnosis. The blood test that Cigna had deemed “not medically necessary” had confirmed a vitamin D deficiency. His doctor had been right, and recommended supplements to boost van Terheyden’s vitamin level.

Still, van Terheyden kept pushing his appeal with Cigna in a process that grew more baffling. First, a different Cigna doctor reviewed the case and stood by the original denial. The blood test was unnecessary, Cigna insisted, because van Terheyden had never before been found to lack sufficient vitamin D.

“Records did not show you had a previously documented Vitamin D deficiency,” stated a denial letter issued by Cigna in April. How was van Terheyden supposed to document a vitamin D deficiency without a test? The letter was signed by a Cigna medical director named Barry Brenner.

Brenner did not respond to requests for comment.

Then, as allowed by his plan, van Terheyden took Cigna’s rejection to an external review by an independent reviewer.

In late June — seven months after the blood test — an outside doctor not working for Cigna reviewed van Terheyden’s medical record and determined the test was justified.

The blood test in question “confirms the diagnosis of Vit-D deficiency,” read the report from MCMC, a company that provides independent medical reviews. Cigna eventually paid van Terheyden’s bill. “This patient is at risk of bone fracture without proper supplementations,” MCMC’s reviewer wrote. “Testing was medically necessary and appropriate.”

Van Terheyden had known nothing about the vagaries of the PXDX denial system before he received the $350 bill. But he did sense that very few patients pushed as hard as he had done in his appeals.

As a physician, van Terheyden said, he’s dumbfounded by the company’s policies.

“It’s not good medicine. It’s not caring for patients. You end up asking yourself: Why would they do this if their ultimate goal is to care for the patient?” he said.

“Intellectually, I can understand it. As a physician, I can’t. To me, it feels wrong.”

Doris Burke contributed research.