Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from July 21, 2020, to July 
23, 2020, as billed with Diagnosis Related Group (DRG) 342. 
 
You asked the Plan to pay for inpatient care billed with DRG 342. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request. The Plan says DRG 342 is not appropriate as the diagnoses of morbid obesity due to excess calories (E66.01) and body mass index (BMI) of 
40-44.9 (Z68.41) are not relevant to the inpatient admission at issue. The Plan argues that DRG 343 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 342. Our 
reviewer says that the diagnoses of morbid obesity due to excess calories (E66.01) and body mass index (BMI) 
of 40-44.9 (Z68.41) are not supported as relevant to this inpatient hospital admission. Our physician reviewer 
found that the enrollee with a history of coronary artery disease with percutaneous intervention, congestive 
heart failure, aortic stent, hypertension, hyperlipidemia, hypothyroidism, nephrectomy for renal cancer and 
obesity, was accepted in transfer for the ongoing evaluation and management of acute appendicitis, having 
presented elsewhere reporting abdominal pain, nausea and vomiting. A computed tomography (CT) scan of the 
abdomen and pelvis revealed findings consistent with acute appendicitis without perforation or abscess. The 
enrollees height was reported to have been 64 inches, with a body weight of 234.35 pounds, yielding a BMI of 
40.2kg/m2, consistent with Class III obesity. 
 
The enrollee received intravenous fluids, intravenous antibiotics, and underwent same-day uncomplicated 
laparoscopic appendectomy. The Operating Surgeon did not describe any difficulty with patient positioning on 
the operating table or with performance of the surgical procedure related to the enrollees body weight or 
habitus. The Anesthesiologist did not document any difficulty with induction of anesthesia, endotracheal 
intubation, intra-operative management, or subsequent reversal of anesthesia and extubating related to the 
enrollees body weight or habitus. There was no consultation or evaluation by a Hospital Nutritionist/Dietitian. 
The Physical Therapist progress notes do not document any mobility issues related to the enrollees body 
weight or habitus; rather, limitation due to post-operative pain and lower extremity weakness was identified. 
The review has determined that the medical records did not support the billing of morbid obesity due to excess 
calories (E66.01) and body mass index (BMI) of 40-44.9 (Z68.41) for the inpatient admission at issue. 
 
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 342 have not been met. Therefore, we decided 
that the Plan does not have to pay for inpatient hospital care provided from July 21, 2020, to July 23, 2020, as 
billed with Diagnosis Related Group (DRG) 342.