top of page
< Back

202112-144163

2022

Empire BlueCross BlueShield HealthPlus

Medicaid

Mental Health, Substance Abuse/ Addiction

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Bipolar, polysubstance abuse, alcohol intoxication.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with bipolar disorder, polysubstance abuse with confusion and agitation in the setting of alcohol intoxication. The patient was noted with an elevated creatinine of 2.1 milligrams per deciliter (mg/dl). The patient was treated for alcohol intoxication due to ongoing agitation and was also treated with intravenous fluid hydration due to elevated renal function. With clinical stability, the patient was transferred to the psychiatric unit for further care of bipolar disorder.

The proposed inpatient admission was not medically necessary.
The patient could have safely and effectively been managed at a lower level of care.

Based on the Milliman Care Guidelines (MCG) criteria, inpatient level of care may be recommended for renal failure as indicated by one or more of the following: three-fold rise in serum creatinine from baseline, serum creatinine greater than four milligrams per deciliter (mg/dL) (354 micromoles per liter) with acute rise greater than 0.5 milligrams per deciliter (mg/dL) (44.2 micromoles per liter) , or reduction of more than 75% (percent) in estimated glomerular filtration rate or anuria indicated by adequate volume status.

The patient was noted with an elevated creatinine of 2.1 milligrams per deciliter (mg/dl). Based on available data, these criteria are not met.

Inpatient admission may be indicated for renal failure if the patient cannot be managed in outpatient or observational care setting as indicated by one or more of the following: clinical status unstable, altered mental status that is severe or persistent, hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, or clinically significant electrolyte abnormality or metabolic abnormality that is severe or persists despite outpatient or observation care treatment, acute treatment of renal failure (eg, dialysis) not feasible or appropriate in observational care setting, other suspected etiology needing inpatient level of care.

Based on available data, these criteria are not met and therefore, the inpatient level of care is not recommended.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.

bottom of page