I got this response from Anthem after asking for the clinical guidelines they used to deny part of my hospital stay:
From Anthem Support:
“Type of Review ER-1 - Medical Letter Rationale ER-1 - You went to the hospital for bleeding in the brain (hemorrhagic stroke). Your doctor wants to extend your stay. The plan clinical criteria considers an extended stay medically necessary when severe problems persist, like worsening weakness or breathing issues. The records we have don’t show severe problems, so the request to stay beyond [date] is denied. This was reviewed using the MCG guideline ‘Stroke: Hemorrhagic (ORG: M-85).’ These guidelines are only available to providers and the authorization team. We don’t have records showing severe issues that would justify a three-day stay.”
Is this true? I thought patients were allowed to access the clinical guidelines when a claim is denied as not medically necessary.