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202305-163366

2023

Empire BlueCross BlueShield HealthPlus

Medicaid

Genitourinary/ Kidney Disorder

Inpatient Hospital

Medical necessity

Upheld

Case Summary

Diagnosis: Urinary tract infection
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial is upheld.


The patient was an adult female admitted for nausea and vomiting. On examination, the patient had abdominal tenderness in the right upper quadrant and epigastric areas. Laboratory studies were remarkable for elevated venous potential of hydrogen (pH) at 7.44, hypokalemia at 3.4, thrombocytopenia at 173, elevated aspartate aminotransferase (AST) at 54, elevated alanine transaminase (ALT) at 41. White blood cell (WBC) count was 8.4. Urinalysis demonstrated 3+ proteinuria, blood, small leukocytes. Electrocardiogram (ECG) demonstrated sinus bradycardia. She was found to have urinary tract infection and was treated with antibiotics and intravenous (IV) fluid. Her condition improved and was discharged in stable condition.

The patient was hemodynamically stable, she was afebrile with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. She was able to tolerate oral diet and did not require total parenteral nutrition and her work up was negative for acute process.

Inpatient admission was not medically necessary, and observation was more appropriate.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.

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