Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on August 2, 2021, to 
August 3, 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 the 
documentation submitted supports the inpatient hospital care as originally billed. The Plan denied your request. 
The Plan says the billed diagnosis codes are not supported in the documentation submitted. 
 
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 principal diagnosis code, A41.9, defined as sepsis, 
unspecified organism and the secondary diagnosis code, J15.6, defined as pneumonia due to other Gram-
negative bacteria. 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 documentation does not support the billed 
principal and secondary diagnosis codes. Our physician reviewer found that the review indicates that the 
enrollee presented to the facility with the chief complaint of shortness of breath, nausea and vomiting. The 
enrollee was acknowledged to have a medical history significant for chronic obstructive pulmonary disease, 
congestive heart failure, chronic kidney disease, chronic pain, obesity, and others. The provider noted in the 
emergency department the enrollee was alert and oriented, "well appearing" and in no acute distress. Systemic 
Inflammatory Response Syndrome (SIRS) criteria such as fever and elevated white blood cell count are 
acknowledged as an appropriate response to an infection to be present, and not necessarily a life-threatening or 
dysregulated response to infection and are thus no longer considered to be criteria for the diagnosis of sepsis. 
The following clinical validation criteria were not supported; the Glasgow Coma Scale was 15 without 
neurological deficit, mean arterial blood pressure values were > 70 mmHg without support of hemodynamic 
instability. No arterial blood gas was drawn, and the enrollees baseline saturation was unclear. However, the 
room air saturation remained > 92% primarily. Platelet counts were > 150K, total bilirubin was < 1.2 mg/dL 
and following fluids given in the setting of dehydration the creatinine values were 1.1 mg/dL. 
 
Additionally, the record was reviewed for secondary diagnosis code J15.6 and following review the 
documentation is maintained to be conflicting. While the provider stated "likely gram negative" pneumonia, the 
provider did not give clear context as to this assessment, and no sputum cultures or other diagnostic testing was 
performed during the one-day encounter.  
 
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 2, 2021, to August 3, 2021, at the Diagnosis Related Group 
(DRG) originally billed.