Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital care provided from June 7, 2021, to 
June 8, 2021, as billed with Diagnosis Related Group (DRG) 082. 
 
You asked the Plan to pay for inpatient care billed with DRG 082. You say that these services were medically 
necessary and are supported in the record. The Plan denied your request.  The Plan says DRG 082 is not supported as the diagnosis of acute respiratory failure, unspecified whether with 
hypoxia or hypercapnia (J96.00) is not supported in the medical record. The Plan argues that DRG 084 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 082. Our 
reviewer says that the diagnosis of acute respiratory failure, unspecified whether with hypoxia or hypercapnia 
(J96.00) is not supported in the medical records for this inpatient admission. Our physician reviewer found that 
the documentation from the medical record supported a 1-day admission for evaluation after a fall. The enrollee 
was found unresponsive on the floor. Upon arrival enrollees Glasgow Coma Scale (GCS) was noted as 3. She 
was noted to have a hematoma and missing teeth. Radiology findings revealed complex facial fractures, 
including bilateral LeFort type I fractures and left LeFort type II fracture and a comminuted, mild displaced 
and minimally depressed left orbital floor fracture. Consult noted that the enrollee needed urgent intubation due 
to her diminished GCS of 3. The emergency department (ED) noted indication for procedure was airway 
protection. A chest x-ray revealed no evidence of a pneumothorax or hemothorax or widened mediastinum. 
Neurological exam revealed nonreactive pupils bilaterally. Physician spoke with family, and they expressed the 
enrollee did not want resuscitation or intubation; once the enrollees family found the enrollee was already 
intubated, they decided to put a do-not-resuscitate (DNR) order in place. Physician documentation noted the 
enrollee had a poor prognosis due to facial fracture and respiratory failure from possible brain contusion from 
fall. Although acute respiratory failure was documented, evidence to support the diagnosis was inconsistent. 
The enrollees vitals upon arrival were as follows: Oxygen concentration (SpO2) 94-100%, respiratory rate 8-
20 bpm, and heart rate 50-94. Rhonchus was noted in ED with diminished respiratory rate but equal breath 
sounds. The review has determined that the medical records did not support the billing of acute respiratory 
failure, unspecified whether with hypoxia or hypercapnia (J96.00). 
 
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 082 have not been met. Therefore, we decided 
that the Plan does not have to pay for the inpatient hospital care provided from June 7, 2021, to June 8, 2021, as 
billed with Diagnosis Related Group (DRG) 082.