Are clinical guidelines only available to providers and not patients?

Seeking Advice
1

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.

3

Yeah, you usually need a subscription to access McMillen Care Guidelines (MCG). I’m not a fan because they focus too narrowly on the main reason for admission and ignore other health conditions, which can lead to denials.

It feels like a tool designed to deny care. I’ve seen denials even when everything technically fit the guidelines, but something minor was missing from their checklist.

I think any insurer using these guidelines should be required to send patients and hospitals a copy of the exact criteria they’re using.

If the hospital works with your insurance, they’ve probably already flagged this for appeal. Sometimes inpatient stays are cheaper than observation because of how billing works.

4

Does your EOB show you owe money for the denied stay?

5

Kellan said:
Does your EOB show you owe money for the denied stay?

Yeah, it does.