Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided from June 21, 2021, to 
June 23, 2021, at the Diagnosis Related Group (DRG) originally billed. 
 You asked the Plan to pay for the inpatient services at the DRG originally billed.. You say that the medical 
records support the billed diagnosis. The Plan denied your request. The Plan says the diagnosis of J15.6 
(Pneumonia due to other gram-negative bacteria) is not supported in the medical record, resulting in a lower 
DRG. While the chest x-ray supported the presence of pneumonia, there was no microbiological confirmation 
of a gram-negative organism. Review of the laboratory data noted a negative legionella urinary antigen. In 
addition, blood and sputum cultures were both negative. 
 
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 a diagnosis of J15.6 (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 services at 
the DRG originally billed. Our reviewer says that the diagnosis of J15.6 (Pneumonia due to other gram-
negative bacteria) is not supported in the medical record. Our physician reviewer found the patient was a then, 
63-year-old female who presented to the facility on June 21, 2021, with reports of worsening shortness of 
breath and a productive cough. The patient reported a chest x-ray two days prior that showed pneumonia. The 
patient's past medical history included fibromyalgia, eclampsia, hepatitis C, hypertension, hypothyroidism, 
inflammatory polyarthropathy, major depressive disorder, osteoarthritis, rheumatoid arthritis, migraine, 
thrombocytopenia, and vitamin D deficiency. Evaluation in the emergency room noted leukocytosis and 
hypoxia requiring supplement oxygen at 2 liters via nasal cannula. The initial chest x-ray indicated mild 
bibasilar infiltrates with small left effusion. The patient was admitted and started on antibiotics for pneumonia. 
The patient was also diagnosed and treated for an acute exacerbation of diastolic heart failure. In the letter of 
dispute, the facility has indicated that "The patient met the degree of associated risk in the setting of reported 
purulent sputum, new onset infiltrate, as well as documented fever and leukocytosis". However, in the absence 
of microbiological confirmation, these findings alone do not validate the condition.  
 
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 from June 21, 2021, to June 23, 2021, at the Diagnosis Related Group 
(DRG) originally billed.