Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on December 22, 2021, 
to December 26, 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 these 
services were billed correctly and are supported in the medical record. The Plan denied your request. The Plan 
says the DRG submitted on this claim is not supported by the medical records provided. 
 
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 unspecified gram-negative sepsis (A41.50), sepsis 
due to methicillin resistant staphylococcus aureus (A41.03), pneumonia due to other aerobic gram-negative 
bacteria (J15.9) and pneumonia due to methicillin resistant staphylococcus aureus (J15.212). 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 these diagnoses are not supported in the medical record. Our physician reviewer found 
that the enrollee presented to the hospital with dyspnea and cough after recent hospitalization following all-
terrain vehicle accident complicated by pneumonia. During this admission, the enrollee had mild to moderate 
hypoxia resolved with low dose oxygen support via nasal cannula, had a Glasgow Coma Scale of 15, normal 
platelet count, normal Creatinine level, normal bilirubin, procalcitonin level was normal, and lactic acid was 
slightly elevated. Nasal swab was negative for Staph aureus, blood culture was without growth, and there were 
no sputum cultures noted as having been performed or resulted. Chest x-ray showed faint infiltrates. The 
provided documentation, therefore, does not clearly show signs of a systemic response to infection leading to 
organ damage to meet the Sepsis 3 criteria. Also, there was no culture results showing the organism causing the 
patient's pneumonia to justify a specific organism pneumonia diagnosis. Therefore, the unspecified gram-
negative sepsis (A41.50), sepsis due to methicillin resistant staphylococcus aureus (A41.03), pneumonia due to 
other aerobic gram-negative bacteria (J15.9) and pneumonia due to methicillin resistant staphylococcus aureus 
(J15.212) would each not be appropriate diagnose for this admission based on the provided documentation. 
Pneumonia, unspecified organism would have been a more appropriate principal diagnosis for this admission.   
 
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 December 22, 2021, to December 26, 2021, at the Diagnosis Related 
Group (DRG) originally billed.