Inpatient Defense Case Study

II. Appeal for a Medically Necessary Inpatient Stay
This section respectfully appeals the decision by Blue Shield of 12/13/2016 and Reference Number: H43381807 to deny me prior authorization for an overnight inpatient stay – a stay that was intended to de-risk any initial periprocedural complications that might follow my previously authorized outpatient surgery.

As to the specifics of these previously authorized surgical procedures (i.e. essentially Carotid Angiography, Angioplasty and Stenting), they were: 1. CPT code: 36224, selective catheter placement, internal carotid artery, unilateral, with angiography of the ipsilateral intracranial carotid circulation and all associated radiological supervision and interpretation, includes angiography of the extracranial carotid and cervicocerebral arch, when performed;
2. CPT code: 61630, balloon angioplasty, intracranial (e.g. atherosclerotic stenosis), percutaneous;
3. CPT code: 36217, selective catheter placement, arterial system; initial third order or more selective thoracic or brachiocephalic branch, within a vascular family; and,
4. CPT code: 75894,
Journals JAMA, Stroke, Circulation, Blue Shield of California’s Health Guideline) that identified and matched my relevant, significant medical problems / co-morbidities from MyCHART (attached) with the corresponding major risk factors / complications associated with this planned surgery. (MyCHART is my documented medical record at Scripps Health in San Diego, CA.) The results of this matching process, a significant and truly long list, produced the well-referenced entries below. The Risk Factors / Complication categories of Stroke and Heart Attack, Bleeding at the Catheter Insertion Site, Infection and Death were provided by Blue Shield in their article “Carotid Artery Stenting Treatment Risks.”