Appeal type: Inpatient Hospital
Decision: Partially Favorable

 We decided that the Plan has to pay for the inpatient hospital services billed with secondary diagnosis code I21.A1. We decided that the Plan does not have to pay for the inpatient hospital services billed with principal diagnosis code K22.10.   You asked the Plan to pay for the inpatient hospital services. The Plan says that the billed diagnosis codes are not supported.  We decided that the Plan has to pay for the inpatient hospital services billed with secondary diagnosis code I21.A1.   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 the inpatient hospital services billed with secondary diagnosis code I21.A1. Our reviewer says that the use of secondary diagnosis code I21.A1 is supported by the records provided. Our physician reviewer found that the cardiac workup was negative otherwise and EGD was completed. Myocardial infarction type II was listed and would meet the simple definition as there were elevated troponins, although there is controversy surrounding this diagnosis. However, there is sufficient documentation to justify the NSTEMI type 2 diagnosis.  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 has to pay for the inpatient hospital services billed with secondary diagnosis code I21.A1.   We also decided that the Plan does not have to pay for the inpatient hospital services billed with principal diagnosis code K22.10.  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 the inpatient hospital services billed with primary diagnosis code K22.10. Our reviewer says that primary diagnosis code K22.10 is not supported by the records provided. Our physician reviewer found that the enrollee is an 89-year-old female with abdominal pain and grade B erosive esophagitis on EGD. No ulcer was identified. Ulcer of the esophagus without bleeding is not supported by the documentation. Also, troponins were 0.114, 0.118, and 0.128.  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 the inpatient hospital services billed with principal diagnosis code K22.10.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.