Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from January 6, 2021, to 
January 21, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that this 
admission was billed correctly and should be paid at the original DRG. The Plan denied your request. The Plan 
says the secondary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle 
cerebral artery (I63.511) is not supported in the medical record. By the time of the transfer to the acute 
inpatient rehab unit, the cerebral infarction was no longer an acute, ongoing active condition. The admission 
was focused on the sequelae of the cerebral infarction (i.e., hemiplegia and hemiparesis), not the cerebral 
infarction itself. As a result, this secondary diagnosis had no impact on patient care so it should not be reported. 
 
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.   
 
In this case, you billed the inpatient services provided with the secondary diagnosis of cerebral infarction due 
to unspecified occlusion or stenosis of right middle cerebral artery (I63.511). 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 the inpatient hospital services at the DRG originally billed. Our reviewer says 
that the secondary diagnosis of cerebral infarction due to unspecified occlusion or stenosis of right middle 
cerebral artery (I63.511) is not supported in the medical record. Our physician reviewer found that the 68-year-
old male, with a history of cerebrovascular accident without residual, hypertension, diabetes mellitus, chronic 
obstructive pulmonary disease and hyperlipidemia, presented to the acute care hospital on December 31, 2020, 
reporting left upper extremity weakness. Neurological imaging ultimately revealed acute right semiovale and 
right occipital lobe infarctions and prominent chronic ischemic white matter disease. On January 6, 2021, the 
patient was transferred from the Acute Care Hospital Inpatient Unit to the Acute Inpatient Rehabilitation Unit 
of the same facility for acute inpatient rehabilitation directed towards the sequelae of the cerebrovascular 
accident which prompted the preceding Acute Care Hospital Inpatient Admission. The Acute Inpatient 
Rehabilitation Unit History and Physical Examination report documented the presence of dysarthria, mild 
nasolabial fold flattening, 4-to-4+ out-of-5 right upper extremity motor strength, 4-to-4+ out-of-5 right lower 
extremity motor strength, 2-to-3 out-of-5 left upper extremity motor strength, and 3+-to-4 out-of-5 left lower 
extremity motor strength. The patient received a comprehensive course of rehabilitation, including Speech 
therapy, Occupational therapy, and Physical therapy directed towards the residual deficits related to the 
preceding cerebrovascular accident. He was also continued on his baseline medications with on-going medical 
management of chronic conditions. He was discharged to home with Home Care Services on January 21, 2021. 
The review has determined that the secondary diagnosis of cerebral infarction due to unspecified occlusion or 
stenosis of right middle cerebral artery (I63.511) was not supported in the medical record. By the time of the 
transfer to the acute inpatient rehab unit, the cerebral infarction was no longer an acute, ongoing active 
condition. The admission was focused on the sequelae of the cerebral infarction (i.e., hemiplegia and 
hemiparesis), not the cerebral infarction itself. As a result, this secondary diagnosis had no impact on patient 
care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital services provided from January 6, 2021, to January 21, 2021, at the Diagnosis Related 
Group (DRG) originally billed.