Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 27, 2021, to 
September 6, 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 
DRG is appropriate and is supported in the medical record. The Plan denied your request. The Plan says the 
submitted DRG is not appropriate in this case, as the medical documentation does not support the billing of 
unspecified severe protein calorie malnutrition (E43). 
 
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 unspecified severe protein calorie malnutrition 
(E43). 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 this diagnosis is not supported in the medical record. Our physician 
reviewer found that the enrollee presented to the emergency department for evaluation of back pain. The 
enrollee had a past medical history of hypertension, diabetes mellitus, myocardial infarction, and diverticular 
disease. The enrollee was diagnosed with hyponatremia and was admitted for further care. The emergency 
department physical exam noted the enrollee was well-developed, with no respiratory distress, alert and 
oriented x3, and had no focal deficits. The enrollees chest x- ray revealed no acute disease, and the computed 
tomography of the head revealed no acute intracranial abnormalities. A nutrition note noted the enrollee had 
severe malnutrition related to chronic illness as evidenced by mild loss of muscle mass, weight loss of more 
than 5%, with an energy intake of less than or equal to 75% of estimated energy requirement for one month. 
The enrollees body mass index (BMI) was 22.92. Discharge summary noted the enrollees nutritional status 
was moderate malnutrition; however, notes also documented severe malnutrition. Protein calorie malnutrition 
(PCM) is the state of inadequate intake of food (as a source of protein, calories, and other essential nutrients) 
occurring in the absence of significant inflammation, injury, or another condition that elicits a systemic 
inflammatory response. The most helpful laboratory studies in assessing malnutrition in a child are 
hematological studies and laboratory studies evaluating protein status. In this case, the medical record 
documentation did not substantiate the diagnosis of severe malnutrition. The review has determined that the 
medical records do not support the billing of unspecified severe protein calorie malnutrition (E43).  
 
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 on August 27, 2021, to September 6, 2021, at the Diagnosis Related 
Group (DRG) originally billed.