The Clinical Justification Provided By Blue Shield For Denying My Inpatient Stay

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As to the clinical justification provided by Blue Shield for denying my inpatient stay, the stated reason in Reference Letter: H43381807 was: “Your doctor has requested approval for coverage of an overnight stay in the hospital after your surgery. This surgery is considered an outpatient procedure per
Milliman(MCG) guidelines (National guidelines upon which we based this decision).
After a review of your medical records from your doctor, we are unable to approve this. Your records do not document significant co-morbidity (other medical conditions which increase your risk of having complications after surgery) to approve overnight hospitalization after your surgery.”

However, in my appeal response, I note that my medical …show more content…

Bilateral Pulsatile Tinnitus, Diagnostic Code 388.30, H93.A3 – “There are risks of stroke due to occlusion of blood vessels supplying normal brain.” [13]
5. Diabetes Mellitus Type 2 with Diabetic Peripheral Neuropathy, Diagnostic Code 250.60, E11.42 – “ Stoke Risk 2-4 Times Higher than Non-diabetics” [5]
6. Diabetes Mellitus with Neurologic Complication, Without Long-term Current Use of Insulin, Diagnostic Code 250.60, E11.49 – “ Stoke Risk 2-4 Times Higher than Non-diabetics” [5]
7. Multiple Vessel Coronary Artery Disease (i.e. Ischemic Heart Disease), Diagnostic Code 414.00, I25.10 – “Patients had a high comorbidity burden [of stroke] … ischemic heart disease” [5]
8. History of Quadruple Coronary Artery Bypass Surgery (i.e. motivated by ischemic Heart Failure) (CABG – 3 arterial internal mammary, 1 great saphenous) – “Patients had a high comorbidity burden [of stroke] … ischemic heart disease” [5]
9. Paroxysmal Supraventricular Tachycardia, Diagnostic Code 427.0, I47.1 – “… found an independent association between PSVT and ischemic stroke.” [6] [similar effect to Atrial Fibrillation]
10. Prolonged QT Interval, Diagnostic Code 794.31, R94.31 – “QTc prolongation is associated with a significantly increased risk of incident stroke.” [7] [similar effect to Atrial Fibrillation]
11. Peripheral Arterial Disease, Diagnostic Code 443.9, I73.9 – “Peripheral artery disease can increase risk for stroke and

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