Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from January 19, 2018, to 
January 23, 2018, as billed with Diagnosis Related Group (DRG) 177. 
 
You asked the Plan to pay for inpatient care billed with DRG 177. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 177 is not 
supported as the diagnosis of encephalopathy, unspecified (G93.40) is not supported in the medical record. The 
Plan argues that DRG 178 is more appropriate in this case. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for inpatient care billed with DRG 177. Our 
reviewer says that the diagnosis of encephalopathy, unspecified (G93.40) is not supported in the medical 
records for this inpatient admission. Our physician reviewer found that the enrollee presented due to family 
report of the enrollee sleeping all the time and not eating for the previous 1 to 2 weeks. The enrollee was 
admitted with work up revealing diagnoses of pneumonia, UTI, and dehydration. Treatment included 
intravenous (IV) antibiotics and IV fluids. Review of the documentation also noted a diagnosis of advanced 
dementia. Per the nursing note in the emergency department, the son described long, ongoing issues with 
dehydration. He reported that she does not eat or drink enough at the nursing home, and there had been no 
sudden changes. The enrollee was sent in purely at family request. The history and physical also noted that the 
son reported a progressive history of increasing confusion, generalized weakness, and overall decline over the 
last few months. The enrollees mental status fluctuated between being alert at times and at other times, unable 
to participate in exam and responding slowly to questions. The discharge summary indicated that on January 
22, 2018, the family noted little improvement, and given advanced dementia, focus was now comfort. The 
enrollee had waxing and waning of mental status consistent with underlying dementia. Review found no 
evidence of a significant improvement in mental status with treatment of the underlying conditions. The 
enrollees mental status was due to progressive decline related to dementia. The review has determined that the 
medical records did not support the billing of encephalopathy, unspecified (G93.40) 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient care billed with DRG 177 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from January 19, 2018, to January 23, 
2018, as billed with Diagnosis Related Group (DRG) 177.