In Michael P. v. Blue Cross & Blue Shield of Texas, No. 20-30361, __F.App’x__, 2021 WL 4314316 (5th Cir. Sept. 22, 2021), Defendants-Appellants Blue Cross and Blue Shield of Texas appealed the district court’s grant of summary judgment to Plaintiff-Appellee Michael P. on his minor daughter’s (“MP”) claim for inpatient care at the Menninger Clinic following her fifth suicide attempt. MP’s fourth suicide attempt occurred just a month earlier and she was hospitalized for twelve days. Blue Cross approved inpatient care from January 26 to February 10, 2016, but denied it from February 11 to March 21, 2016. The district court found that there was some evidence to support Blue Cross’s determination that M.P. no longer posed an “imminent risk” of suicide or self-harm after February 10th and that a lower level of care might have been feasible, but it granted Plaintiff’s motion for summary judgment. The Fifth Circuit reversed the decision of the district court because it found that Blue Cross’s decisions to apply the Milliman Care Guidelines’ (MCG) acute inpatient admission criteria to the claim and to deny coverage based on the MCG criteria was supported by substantial evidence.
Plaintiff argued that Blue Cross should have applied the medical necessity of MP’s extended stay against “residential criteria” rather than “acute inpatient criteria.” The court rejected this argument because MP received acute inpatient care throughout her stay. It was reasonable for Blue Cross to continue to use the MCG’s criteria for inpatient admission for the duration of MP’s stay since Plaintiff did not cite to any “continued treatment or discharge” standard that Blue Cross should have employed instead. It was also not arbitrary and capricious for Blue Cross to rely solely on the MCG which focuses on the alleviation of acute symptoms rather than the treatment of the patient’s underlying conditions. The terms of the self-funded medical plan did not require that Blue Cross continue to cover treatment at an acute inpatient level until MP’s underlying condition was resolved.
The MCG dictates that the inpatient level of care is appropriate if (1) there is “patient risk” and (2) the treatment situation and needs are appropriate at that level and not a lower level of care. “Patient risk” means that the patient is an imminent danger to herself or others, has a life-threatening inability to perform self-care, and has a severe disability or disorder requiring acute intervention, or has a severe comorbid substance abuse disorder that must be controlled to stabilize the primary psychiatric disorder. The court found that substantial evidence supports Blue Cross’s determination that none of these conditions were present after February 10, 2016.
The inpatient treatment level is appropriate if the patient is not willing to participate voluntarily, voluntary treatment at a lower level of care is not feasible, there is a need for physical restraint or involuntary control, or around-the-clock medical or nursing care is needed to address the patient’s symptoms. The court found that substantial evidence supports Blue Cross’s determination that an acute, inpatient level of treatment was not appropriate after February 10th. Even though less-than-acute-inpatient treatment did not work after MP’s first four suicide attempts, Blue Cross had substantial evidence to conclude that 15 days of acute inpatient care was all that was medically necessary. For these reasons, the court concluded that Blue Cross did not abuse its discretion and reversed the decision of the district court with instructions to enter judgment in favor of Defendants.
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